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THE  PSYCHONEUROSES 

AND  THEIR  TREATMENT 

BY 

PSYCHOTHERAPY 


BY 

PROFESSOR  J.  I^EJERINE 

PROFESSOR    OF    THE    CLINIC    FOR    NERVOUS    DISEASES    OF    THE    FACtXTY    OF    MSDICINB    OF    THE 

VfNU'ERSITY  OF  PARIS 

AND 

DR.  E.  GAUCKLER 


ANCIEN   INTERNE  OF  THE  HOSPITALS  OF  PARIS 


AUTHORIZED  TRANSLATION  BY 

SMITH  ELY  JELLIFFE,  M.D.,  Ph.D. 

ADJXJNCT  PROFESSOR  OF  DISEASES  OF  THE  MIND  AND  NERVOL'S  SYSTEM,  POST  GRADUATE  MEDICAL 
SCHOOL  AND  HOSPITAL;     VISITING  NEUROLOGIST,   CITY  HOSPITAL,  NEW  YORK 


SECOND  ENGLISH  EDITION 


PHILADELPHIA  &  LONDON 
J.  B.  LIPPINCOTT  COMPANY 


'7^C343 

D4- 


BIOLOGY 
O 


COPYRIGHT,   I9I3 
BY  J.    B.   LIPPINCOTT  COMPANY 


COPYRIGHT,    19IS 
BY  J.   B.  LIPPINCOTT  COMPANY 


y  I, "I 


Electrotyped  and  Printed  by  J.B.  Lippincott  Company 
The  Washington  Square  Press,  Philadelphia,  U.  S.  A. 


TRANSLATOR'S  PREFACE 

In  translating  this  work,  I  have  had  in  mind  a  very  definite  purpose. 
For  a  number  of  years,  like  many  another,  I  have  been  struck  by  the 
immense  number  of  minor  psychic  disturbances  which  render  numerous 
individuals  unhappy,  discontented,  ill,  unable  to  hold  their  own  in 
their  milieu,  even  making  confirmed  invalids  of  many. 

These  individuals,  variously  classified  as  to  their  maladies,  at  differ- 
ent times,  as  suffering  from  functional  neuroses,  nervousness,  neuras- 
thenia, phobias,  fixed  ideas,  obsessions,  hysteria,  psychoneuroses,  etc., 
have  been  neglected  for  many  years  as  objects  of  scientific  medical 
inquiry.  The  reasons  for  this  are  obvious.  They  centre  about  the 
cardinal  fact  that  the  psychic  life  of  the  human  being  is  the  most 
complex  series  of  phenomena  in  the  most  highly  evolved  creature  with 
which  human  intelligence  is  acquainted. 

The  psychic  problems  of  the  individual  have  been  left  for  the  most  part 
to  the  poet,  the  artist,  the  dramatist,  and  the  story  writer. 

I  dp  not  mean  that  the  physicians  of  times  past  have  not  made 
serious  attempts  to  understand  these  questions.  They  have,  and  the 
student  of  medical  history  may  well  admire  the  results  obtained,  even 
if  to-day  they  may  seem  inadequate,  if  not  provoking.  Even  taking 
this  knowledge  into  consideration,  however,  it  appears  that  the  problems 
of  medicine  have  been  so  many,  and  so  difficult  of  solution,  that  the 
human  mind  has  naturally  and  wisely  grasped  at  those  for  which  some 
adequate  solution  seemed  practicable.  It  is  for  this  reason  that  the 
comparatively  simpler  problems  of  the  bodily  activities,  their  modifica- 
tions, etc.,  have  received  their  wealth  of  study,  which  is  one  of  the 
crowning  glories  of  medical  science  in  the  last  century. 

The  time  came,  however,  when  the  intricacies  of  the  nervous  system 
conunenced  to  be  resolved,  and  scientific  medicine  arrived  at  a  point 
where  its  hypotheses  began  to  yield  valuable  results  in  the  fields 
of  neurology  and  psychiatry.  With  the  establishment  of  firmer  founda- 
tions, it  became  worth  while  to  delve  into  psychic  problems,  with  some 
hope  of  sound  deductions  and  practical  results,  and  within  the  past  few 
generations  we  have  seen  scientific  medicine  take  its  place  in  this  domain 
heretofore  left  to  the  thousand  and  one  uninformed  and  quasi-scientific 
cults  which  have  for  centuries  constituted  parasitic  foci  in  every 
community. 

It  was  with  the  intention  of  furthering  a  knowledge  of  what  scientific 
medicine  could  do  in  the  domain  outlined  that  I  first  translated  Dubois' 
excellent  work  on  the  ''Psychoneuroses."  Its  fundamentail  postulate 
was  an  appeal  to  the  intelligence  of  the  individual. 

333458  ^"^ 


iv  TRANSLATOR'S  PREFACE. 

Dubois,  however,  was  incomplete.  He  did  not  lay  sufficient  emphasis 
upon  the  instinctive,  or,  more  widely  speaking,  the  em"otional  side  of 
the  human  machine,  in  its  psychical  situations.  It  is  for  this  reason 
that  I  have,  with  the  aid  of  my  wife,  translated  the  present  volume, 
which  is  the  product  of  Professor  Dejerine  of  Paris,  and  one  of  his 
former  assistants.  Dr.  Gauckler. 

Herein  is  found  that  emphasis  lacking  in  the  work  of  Dubois.  Herein 
Dejerine  and  Gauckler  uncover  the  emotional  factors  which  are  present 
in  all  of  the  group  of  disorders  under  discussion.  This  work  provides  us, 
in  the  best  manner  at  present  available,  the  other  side  of  the  human 
being,  which  had,  I  feel,  been  somewhat  neglected  by  former  authors. 

The  reading  of  this  book  will  show  how  many  patients  may  be 
treated  and  cured  without  the  more  detailed  analyses  elaborated  to  meet 
more  complex  situations. 

Just  as  in  the  domain  of  internal  medicine  a  compound  cathartic 
pill  will  relieve  the  vast  majority  of  constipations,  requiring  only  in  a 
smaller  percentage  of  cases  a  more  intricate  and  time-consuming  gastro- 
intestinal therapy,  so  in  the  domain  of  the  psychoneuroses  a  prompt 
handling  of  an  emotional  situation,  or  a  sound  dialectic  may  secure 
for  a  large  number  of  patients  the  relief  necessary  to  effect  an  adjust- 
ment, while  for  a  lesser  number,  although  their  number  is  by  no  means 
small,  only  a  psycho-analysis  will  effect  a  cure. 

With  these  few  words  we  leave  the  work  to  the  judgment  of  the 
individual  reader.  The  hope,  that, it  will  prove  of  some  service  to  all, 
patients  as  well  as  their  physicians,  has  been  the  stimulus  and  purpose 
which  has  led  to  its  translation. 

Smith  Ely  Jellipfe. 

April,  1913. 


PREFACE 

When,  more  than  thirty  years  ago,  I  began  to  devote  myself  to 
the  study  of  diseases  of  the  nervous  system,  I  was  struck,  from  the  very 
beginning  of  my  practice,  with  the  slight  success  which  resulted  from 
treatment  of  neuropaths  by  medicines,  whether  combined  or  not  with 
physical  measures,  and  little  by  little  I  was  led,  by  personal  experience, 
to  ask  myself  whether  it  would  not  be  wise,  in  the  case  of  all  patients 
coming  under  the  classification  of  neurasthenia  or  hysteria,  to  depart 
from  the  usual  therapeutic  methods,  and  seek  the  cause  of  their  disease 
outside  of  the  objective  symptoms  which  they  presented. 

I  thus  became  more  and  more  convinced  that  it  was  not  the  physical, 
but  rather  the  moral  which  was  the  cause  of  all  the  symptoms  of  which 
these  patients  complained,  and  finally,  after  having  practised  Dr.  Weir 
Mitchell's  methods  for  several  years,  my  convictions  were  established. 
In  using  this  method  of  treatment,  which  is  based  practically  on  isolation, 
rest  in  bed,  over-feeding,  douches,  massage,  and  electricity,  in  fact  on 
purely  physical  measures,  I  was  not  long  in  discovering  that  unless  the 
patient's  state  of  mind  improved  the  therapeutic  results  were  far  from 
satisfactory. 

It  was  thus  that  I  soon  came  to  see  that  in  order  to  treat  neuropaths, 
with  the  hope  of  curing  them,  the  first  and  most  important  thing  was 
to  get  hold  of  their  morale,  in  other  words,  to  practise  psychotherapy. 
This  is  what  I  have  been  doing  for  the  last  twenty-five  years. 

The  influence  of  the  morale  on  the  physique  has  been  known  in  all 
ages.  It  is  in  fact  a  popular  belief  that  the  health  may  be  seriously 
affected  by  grief  or  vexation,  but  physicians  have  been,  as  a  rule,  the 
last  persons  to  recognize  that  these  might  be  connected  with  a  very 
special  class  of  affections,  requiring  particular  treatment,  based  not  on 
symptoms  but  on  causes:  and,  without  wishing  to  deny — at  least  in 
many  cases — ^the  accuracy  of  the  old  adage  ''Mens  sana  in  corpore  sano/' 
I  nevertheless  believe  that,  in  the  case  of  most  neuropaths,  whatever 
may  be  their  symptomatology,  the  saying  is  not  correct.  With  them, 
as  a  matter  of  fact,  if  the  body  is  not  sound  it  is  because  their  morale  is 
unhealthy,  and  because  they  have  either  suffered  or  are  stiU  suffering 
morally  or  spiritually. 

As  a  method  of  general  education,  or  moral  guidance,  psychotherapy 
is  as  old  as  the  world.  All  philosophies,  and  all  religions,  above  all, 
the  Catholic  religion — for  the  psychotherapist  is  nothing  more  than  a 
confessor,  or  director  of  the  lay  conscience — ^have  applied  it,  or  are  still 
applying  it.  Few,  however,  are  the  physicians  who  understand  this, 
or  who  know  how  to  make  use  of  it,  when  they  know  the  cause. 

(V) 


vi  PREFACE. 

To  be  convinced  of  this,  one  only  has  to  see  what  a  large  number 
of  neuropaths  are  being  subjected  to  some  physical  treatment,  as  if 
they  had  some  true  organic  lesions.  I  am  alluding  to  those  patients, 
whose  number  is  legion,  whom  I  have  described  under  the  name  of 
false  gastropaths,  false  enteropaths,  false  cardiopaths,  false  genito- 
paths,  sufferers  from  spinal  disease,  and  false  cerebral  disease;  who 
present  symptoms  which  often  seem  serious,  but  whose  origin  is  wholly 
psychic,  and  who  are  treated  every  day  purely  and  solely  on  the  lines 
of  symptomatic  therapy,  with  the  result  that  the  idea  becomes  more 
firmly  fixed  in  their  minds,  that  there  is  some  disease  localized  in  the 
organ  of  which  they  complain.    I  have  seen  thousands  of  these  invalids. 

I  hold  that  the  physicians  who  understand  and  know  how  to 
practise  psychotherapy  are  still  very  few  in  number.  I  do  not,  how- 
ever, consider  direct  suggestion  as  a  psychotherapeutic  measure,  either 
when  produced  more  or  less  openly  in  the  waking  state  or  by  means 
of  hypnosis.  Such  methods  have  the  serious  defect  of  acting  only  on 
the  subconscious,  and  on  the  cerebral  automatism,  and  are  not  directed 
to  the  superior  faculties  of  the  individual. 

f  Suggestion,  though  much  more  frequently  used  in  hysterical  cases 
than  in  troubles  of  neurasthenic  origin,  whether  practised  in  the  waking 
state  or  during  hypnotic  sleep,  is  directed  only  to  the  symptom,  and 
not  to  the  cause;  its  action  is  only  on  the  surface,  it  does  not  reach 
the  depths.  By  this  process  one  often  succeeds  more  or  less  quickly, 
in  certain  cases,  in  getting  rid  of  a  paralysis,  a  contracture  or  an  anses- 
thesia  in  an  hysteric.  But,  without  taking  the  drawbacks  into  con- 
sideration, and  they  are  very  numerous,  the  result  is  very  uncertain, 
unless,  by  winning  the  confidence  and  appealing  to  the  reason  of  the 
patient,  or  in  other  words  by  means  of  psychotherapy,  one  succeeds 
in  making  him  confess  his  manner  of  living,  and  explains  to  him  how 
and  why  he  fell  ill,  and  how  and  why  he  can  become  cured,  so  that  he 
will  not  relapse. 

^  Even  though  these  methods,  which  are  directed  only  to  the  cerebral 
automatism,  are  sometimes  successful  in  causing  some  of  the  objective 
manifestations  of  a  hysterical  condition  to  disappear,  they  are  abso- 
lutely without  efficiency  when  it  comes  to  the  very  complex  and  in- 
tricate symptoms  of  a  neurasthenic.  For  here  the  mental  condition 
is  wholly  different.  One  cannot  cure  a  false  gastropath  or  cardiopath 
by  a  brusque  command.  It  is  a  case  for  mental  pedagogy,  which  often 
requires  a  long  time  and  careful  development  to  be  effectual. 

It  has  been  stated  repeatedly,  and  with  some  reason,  that  isolation 
in  a  sanitarium  is  fundamental  in  the  treatment  of  the  psychoneuroses. 
In  a  general  way  this  is  true,  but  it  is  not  absolutely  imperative.  In 
the  case  of  many  neuropaths  isolation  is  not  necessary,  and  the  psycho- 
therapist need  not  insist  on  it.     Isolation,  in  fact,  is  nothing  but  a 


PREFACE.  vii 

means,  without  which,  in  many  eases,  it  would  be  impossible  to  practise 
psychotherapy,  and  which  has  its  special  indications. 
y  A  sojourn  in  a  sanitarium  is  possible  only  to  the  wealthy  or  those 
who  are  comfortably  off,  and  is  wholly  out  of  the  question  for  the 
poorer  classes  of  society.  But  the  psychoneuroses  are  not  met  ex- 
clusively among  the  well-to-do.  Neurasthenia  and  hysteria  are,  in  fact, 
very  common  among  the  working  population  of  Paris,  and  are  often 
found  in  very  severe  forms.  I  have  therefore  tried  to  introduce  in 
the  hospital  the  suitable  conditions  of  treatment  which  one  would  find 
in  a  sanitarium,  and  for  fifteen  years  I  have  established  in  my  service 
at  the  Salpêtrière  an  isolation  and  psychotherapeutic  ward,  where 
several  thousand  patients  have  been  treated.  The  results  obtained  by 
this  measure  have  far  surpassed  the  hopes  I  had  in  the  beginning,  for 
they  have  proved  quite  as  satisfactory,  and  even  more  rapid,  than 
those  in  private  practice.  I  will  not  go  into  the  details  of  my  methods 
of  working  in  the  hospital.  The  reader  who  is  interested  in  this  ques- 
tion will  find  all  the  necessary  information  in  a  work  entitled  '  '  Isolement 
et  Psychothérapie,  '  '  published  in  1904,  by  my  pupils  Camus  and  Pagniez. 
I  merely  make,  in  passing,  the  statement  that  at  the  Salpêtrière,  as  well 
as  in  the  city,  it  is  the  moral  treatment  which  is  the  cause  of  the  suc- 
cess obtained. 

/  According  to  some  authors,  particularly  Dubois  (of  Berne),  psycho- 
therapy ought  to  be  ''rational,"  that  is,  based  solely  on  reasoning  and 
argument.  I  have  always  been  of  the  opposite  opinion,  and  I  have 
frequently  expressed  myself  on  this  subject,  both  in  my  courses  at 
the  Faculty  of  Medicine  and  in  my  clinical  lectures  at  the  Salpêtrière. 
If  reason  and  argument  were  sufficient  to  "change  one's  state  of  mind," 
the  neuropaths  would  find  in  the  writings  of  the  moralists  and  philoso- 
phers, and  spiritual  advisers,  everything  they  would  need  to  recon- 
struct their  morale,  and  consequently  their  physical  well-being,  and 
therefore  they  would  have  no  need  of  a  psychotherapist. 

Reasoning  by  itself  is  indifferent.  It  does  not  become  a  factor  of 
energy  or  creator  of  effort;  but  the  moment  an  emotional  element 
appears  the  personality  of  the  subject  whose  mentality  .one  is  seeking 
to  modify,  is  moved  and  affected  by  it.  According  to  my  way  of 
thinking,  it  is  an  error  to  consider  both  the  judgment,  which  is  a 
primitive  phenomenon,  and  the  impression  or  sentiment  which  follows 
it  as  psychological  processes  of  the  same  nature.  The  impression  and 
sentiment  are  nothing  but  the  result  of  the  more  or  less  ready  adapta- 
tion of  our  personality  to  the  judgment  which  caused  them,  and 
though  secondary  are  no  less  able  to  provoke  reactions. 

From  my  point  of  view,  psychotherapy  depends  wholly  and  ex- 
clusively upon  the  beneficial  influence  of  one  person  on  another.  One 
does  not  cure  an  hysteric  or  a  neurasthenic  nor  change  their  mental 
condition  by  reasoning  or  by  syllogisms.    They  are  only  cured  when  they 


viii  PREFACE. 

come  to  believe  in  you.  In  short,  psychotherapy  can  only  be  effective, 
when  the  person  on  whom  you  are  practising  it  has  confessed  his  entire 
life,  that  is  to  say,  when  he  has  absolute  confidence  in  you. 

Between  reasoning,  and  the  acceptance  of  this  reasoning  by  the 
patient,  there  is,  I  repeat,  an  element,  on  the  importance  of  which  I 
cannot  insist  too  strongly;  it  is  sentiment  or  feeling.  It  is  feeling 
which  creates  the  atmosphere  of  confidence  without  which,  I  hold,  no 
psychotherapy  is  possible,  that  is  to  say,  unless  reasoning  produces 
effective  action  there  is  no  '^persuasion."  I  am,  in  fact,  convinced, 
and  have  been  so  for  a  long  time,  that  in  the  moral  sphere  the  bare 
idea  produces  no  effect,  that  is  to  say,  the  idea  alone  does  not  move 
one,  unless  it  is  accompanied  by  an  emotional  appeal  which  makes  it 
acceptable  to  consciousness  and  thus  brings  about  conviction.  There  is 
something  analogous  to  faith  in  this,  some  individual  element  which 
makes  the  success  of  the  psychotherapist  depend  upon  his  personality. 

This  is  the  one  and  only  place  to  refer  to  the  ancient  adage — ''It  is 
faith  that  saves  ...  or  cures.*' 

I  have  been  aided  in  the  collaboration  of  this  work  by  one  of  my 
pupils,  Dr.  Gauckler,  with  whom  I  have  already  published  several  works 
on  psychotherapy. 

J.  Dejerine. 


é 


CONTENTS 


PAGS 

Introduction xiii 

PART  I. 

Analytical  Study  op  Functional  Manifestations  . .   1 

Chapter  I. 

Functional  Manifestations  of  the  Digestive  System 2 

Disturbances  of  Appetite 2 

A.  Mental  Anorexia 2 

B.  Quantitative  Disturbances  of  the  Appetite  Due  to  Excess 8 

C.  Elective  Anorexias 10 

Functional  Digestive  Manifestations  Properly  So  Called 11 

A.  Functional  Disturbances  of  the  First  Three  Stages  of  Digestion.  11 

B.  Gastric  Symptoms  in  Nervous  Patients 14 

1.  Simple  Dyspepsias  of  Neurasthenics 16 

2.  Gastric  Obsessions  and  Phobias 17 

3.  Established  False  Gastropathies 22 

4.  Dilatation  of  the  Stomach  in  Nervou^Patients 32 

5.  Vomiting  as  a  Neuropathic  ManifestatR)n 34 

C.  Functional  Troubles  Connected  with  Defecation,  and  Their  Con- 

sequences   37 

Nervous  Diarrhœas 38 

Neuropathic  Constipation 39 

Neuropathic  Constipation  and  Diarrhœa;  Their  Immediate  and 

Ultimate  Consequences 41 

D.  Intes'îîjîal  Manifestations  of  Neuropaths 42 

Hk  Chapter  II. 

FUNCTION^^^^^^WATlONS  IN  THE   UrINARY  OrGANS 46 

A.  Floa^^^^^Hœy  in  Connection  with  the  Psychoneuroses 46 

B.  MoDi^l^Jp  of  the  Urinary  Secretion 47 

C.  Disturbances  op  Micturition 51 

Chapter  III. 

Functional  Manifestations  of  a  Genital  Nature 58 

A.  Genital  Troubles  of  Men 58 

B.  Sexual  Manifestations  of  Women 69 

1.  True  Genital  Localizations 72 

2.  Female  Frigidity 76 

3.  Neurasthenic  Conditions  op  Sexual  Origin 77 

C.  False  Gynecological  Manifestations 79 

Chapter  IV. 

Functional  Manifestations  in  the  Respiratory  Apparatus 82 

(ix) 


X  CONTENTS. 

Chapter  V. 

The  Functional  Manifestations  of  the  Cardiovascular  Apparatus 92 

A.  The  Heart 92 

1.  Action  of  Emotion  on  the  Heart 92 

2.  Phobic  Manifestations  and  Pericardiac  Fixations 93 

B.  Vascular  Manifestations 98 

Chapter  VI. 

Cutaneous  Functional  Symptoms 101 

1.  Action  of  Emotion  on  the  Skin  and  the  Cutaneous  Functions.  101 

2.  Lasting  Vasomotor,  Secretory,  or  Trophic  Symptoms,  Both  Dif- 

fused AND  Localized 102 

3.  Phobic  Manifestations 106 

Chapter  VII. 

Fxjnctional  Symptoms  in  the  Neuro-Muscular  Apparatus 109 

1.  Fatigue,  Fatigu ability.  Exhaustion  and  Their  Functional  Con- 

sequences   109 

2.  Disturbances  of  Equilibrium 125 

3.  Choreas,  Choreiform  Movements,  and  Tremors 131 

4.  Contractures  and  Paralyses 136 

Chapter  VIII. 

Diffuse  or  Localized  Disturbances  of  Sensibility 141 

A.  Objective  Disturbances  of  Cutaneous  Sensibility 143 

(a)  Anesthesia 143 

(b)  The  Hyperesthesia 151 

B.  Subjective  Disturbances  of  Sensibility 153 

Chapter  IX. 
Functional  Manifestations  of  the  Sense  Organs ^^^^ 157 

Chapter  X. 

Nervous  and  Psychic  Manifestations  Properly  So  Called 168 

A.  Disturbances  of  Sleep 168 

B.  Headache 180 

C.  Disturbances  of  the  Reflexes , 181 

D.  Disturbances  of  Speech 184 

E.  Acquired  Disturbances  of  Psychological  Functions 185 

F.  Phobic  Manifestations 194 

Chapter  XI. 
Functional  Manifestations  and  Organic  States 199 

Chapter  XII. 
General  Diagnosis  op  Functional  Manifestations 205 


CONTENTS.  xi 

PART  II. 

Synthetic  Study  of  the  Psychoneuroses  and  Theib  Functional  Manifes- 
tations  213 

Chapter  XIII. 
Neurasthenia  and  Organic  Conceptions  Concerning  It 214 

Chapter  XIV. 
The  Rôle  of  Emotion  and  Emotionalism  in  the  Genesis  of  the  Psycho- 
neuroses 219 

Emotional  Stimuli  of  External  Origin.    Emotional  Shock 219 

Emotional  Stimuli  of  Internal  Origin 220 

Immediate  Psychological  Modifications  Produced  by  Emotional  Stimuli  221 
Later  Psychological  Actions  Exercised  by  the  Emotions.     Preoccu- 
pations   223 

Physical  Phenomena  Produced  by  Emotion.    Anguish  and  Hysterical 

Attacks 224 

Relations  Between  the  Psychical  and  the  Physical  Disturbances  . . .  227 

Emotions  Varying  According  to  Individuals 228 

Emotionalism  and  its  Factors 229 

Physical  Conditions  which  Exaggerate  Emotionalism 231 

Individual  Physical  Reactions  of  Emotional  Origin 232 

The  Emotions.    Hysteria  and  Neurasthenia 233 

The  Nature  of  Emotional  Causes  which  Engender  the  Psychoneuroses  236 
The  Factors  of  the  Persistence  of  the  Emotional  Idea  in  Consciousness  239 

Chapter  XV. 
What  Does  not  Belong  to  Neurasthenia.    What    Does    not    Belong   to 
Hysteria 241 

Chapter  XVI. 
How  One  Becomes  Neurasthenic 250 

Chapter  XVII. 
General  Conceptions  of  Hysterical  Symptoms 263 

Chapter  XVIII. 
General  Conception  of  Functional  Manifestations 271 

PART  III. 
The  Treatment  of  the  Psychoneuroses.    Psychotherapy  and  its  Adjuvant 
Processes 274 

Chapter  XIX. 

Critical  Study  of  the  Treatment  of  the  Psychoneuroses 274 

Direct  Suggestion 277 

Persuasion 283 

Chapter  XX. 
The  Examination  and  Questioning  of  the  Neuropath 286 


xii  CONTENTS. 

Chapter  XXI. 
The  Moral  and  Mental  Substratum.    Its  Psychotherapy 292 

Chapter  XXII. 
A  General  Psychotherapy  op  Functional  Manifestations 305 

Chapter  XXIII. 
The  Adjuvants  op  Psychotherapy 311 

Chapter  XXIV. 

Special  Therapy  op  the  Various  Functional  Manifestations 320 

I.  Functional  Manifestations  in  the  Digestive  Organs 320 

A.  Disturbances  of  the  Appetite 320 

B.  Disturbances  of  the  First  Three  Stages  op  Digestion 322 

C.  Gastric  Manifestations  of  Nervous  People 324 

D.  Intestinal  Manifestations  of  Neuropaths:    Diarrhœa  and  Con- 

stipation    330 

II.  Functional  Manifestations  in  the  Urinary  Apparatus 333 

A.  Disturbances  of  the  Urinary  Secretion 333 

B.  Disturbances  op  Urination  or  Micturition.    False  Urinaries.  .  334 

III.  Functional  Manifestations  in  the  Genital  Apparatus 336 

A.  Genital  Troubles  in  Men 336 

B.  Sexual  Manifestations  of  Women 342 

C.  Gynecological  Pseudo-manifestations 346 

IV.  Functional  Manifestations  in  the  Respiratory  Apparatus 347 

V.  Special  Therapy  in  Cardiovascular  Manifestations 350 

VI.  Functional  Manifestations  of  the  Skin 351 

Chapter  XXV. 

Special  Therapy  of  Functional  Manifestations  (Continued) 353 

I.  The  Therapy  op  Functional  Disturbances  in  the  Neuro-muscular 

Apparatus 356 

A.  Physical  Asthenia 356 

B.  Disturbances  of  Equilibrium 358 

II.  Special  Therapy  of  Disturbances  of  Sensibility.    Pains 359 

III.  Therapy  of  the  Functional  Manifestations  op  the  Organs  of  Sense.  361 

IV.  Therapy  op  Nervous  and  Psychic  Manifestations.  Properly  So  Called  361 

A.  Disturbances  of  Sleep 361 

B.  Headache 365 

C.  Psychic  Disturbances 366 

V.  Special  Therapy  op  Hysterical  Symptoms 369 

Chapter  XXVI. 
Psychotherapy  as  Regarded  by  Physicians  and  Patients 373 

Chapter  XXVII. 
Prophylaxis  op  the  Psychoneuroses.    The  Moral  Rôle  op  the  Physician. 
Conclusions 382 

Index 393 


INTRODUCTION 

This  work  is  devoted  td  the  study  of  the  psychoneuroses,  and  their 
treatment.  In  it  will  be  found  the  ideas  which  have  been  formed  by 
one  of  us  who  has  spent  thirty  years  in  daily  contact  with  neuropaths. 
In  attending  these  patients,  and  noting  the  manner  in  which  they  have 
been  treated,  it  has  seemed  to  us  that  many  physicians  have  held  ideas 
concerning  the  nature  of  the  psychoneuroses  that  are  not  only  incom- 
plete and  inexact,  according  to  our  lights,  but  are  also  therapeutically 
dangerous.  This  does  not  imply  ignorance  on  their  part,  but  rather 
that,  having  been  brought  up  on  doctrines  and  methods  which  are 
excellent  in  their  place,  they  have  extended  their  application  to  a 
branch  of  medicine  like  the  psychoneuroses,  with  which  they  have 
nothing  to  do. 

All  advance  work  in  modem  medicine  is  the  direct  result  of 
progress  in  pathological  anatomy  and  laboratory  work.  These  have 
enabled  us  to  get  a  very  much  more  exact  idea  of  the  human  mechanism, 
and  the  various  troubles  that  may  afflict  it.  But  the  fact  has  been 
quite  overlooked  that  modifications  of  physical  energy  are  not  the  only 
ones  in  which  physicians  should  be  interested. 

All  physicians  rebel  at  the  idea  of  any  dissociation  which  would 
separate  the  physical  organism  on  the  one  haad  from  the  psychic  and 
moral  organism  on  the  other.  But,  both  instinctively,  and  as  a  result 
of  their  education,  the  majority  of  them  have  a  tendency  to  subordinate 
the  disturbances  of  the  psychic  life  to  those  of  the  physical,  and  to 
always  look  for  some  initial  somatic  change.  They  refuse  to  even 
consider  the  existence  of  illnesses  which  owe  their  origin  to  any  ante- 
cedent psychic  or  moral  disturbance.  But,  there  exists,  according  to 
our  way  of  thinking,  a  very  special  nosological  group,  of  much  impor- 
tance, whose  symptomatology  is  caused  solely  by  a  primitive  modifica- 
tion of  the  moral  or  mental  state,  followed  by  a  whole  series  of  secondary 
manifestations.  The  affections  which  come  under  this  heading  are  known 
as  the  psychoneuroses. 

This  book  is  wholly  devoted  to  the  development  of  this  point  of 
view.    It  will  be  divided  into  three  parts. 

The  first,  which  is  analytical,  will  be  devoted  to  the  study  of 
functional  manifestations,  that  is,  to  the  study  of  all  the  symptoms 
which  are  observed  in  the  course  of  the  psychoneuroses,  whose  exact 
nature  we  wish  to  ascertain. 

In  the  second,  the  synthetic,  we  shall  endeavor  to  make  plain  the 
general  mechanism  of  the  foundation  of  the  psychoneuroses,  as  well  as 
their  variations  and  nature. 

In  the  third,  which  is  therapeutic,  will  be  set  forth  the  psycho- 
therapeutic proceedings  and  helps  which  we  feel  are  the  only  measures 
which  should  be  used  in  the  treatment  of  the  psychoneuroses. 

(xiii) 


PSYCHOTHERAPY 

FIRST  PART 

Analytical  Study  of  Functional  Manifestations. 

We  shall  study,  under  the  name  of  functional  manifestations,  all 
those  persistent  symptoms  and  troubles  of  which  neuropaths  complain, 
and  which  have  been  created  in  these  patients  without  any  antecedent 
lesion  of  the  body. 

*  This  definition  is  only  provisional.    It  is  made  sufficiently  broad  for 
the  moment  not  to  limit  the  object  of  our  study. 

As  there  is  no  mechanism,  organ,  or  region  of  the  body  which 
cannot  become  the  seat  of  a  functional  manifestation,  it  would  seem 
necessary  for  the  various  parts  of  the  organism  to  be  involved  in  equal 
proportions.  But  there  are  numerous  reasons  for  the  variability  of 
frequency  which  exists.  Without  dwelling,  for  the  moment,  on  the 
part  which  education,  whether  medical  or  personal,  plays  in  the  symp- 
toms felt  by  these  patients,  we  must  make  one  statement,  large  in 
theoretic  consequences,  which  we  will  make  good  later.  Some  of  the 
functions  of  the  body  are  completely  automatic,  and  never  require  any 
direction  from  the  superior  centres.  Such  is  the  function  of  circulation. 
Others,  on  the  contrary,  especially  the  digestive  and  genital,  and  in 
part  the  urinary,  are  functions  which,  at  least  in  their  ultimate  accom- 
plishment, depend  upon  various  mental  representations,  and  call  the 
will  into  play.  There  are  functions  on  which  the  action  of  the  will  is 
felt,  but  in  a  purely  contingent  manner,  such  as  the  respiratory  function. 
Finally,  even  among  the  functions  which  do  not  come  under  the  in- 
fluence of  the  wiU,  there  are  none  whose  automatism  may  not  be  more 
or  less  affected  by  the  influence  of  the  emotions. 

But  the  fact  is  not  without  signiflcance  that  those  very  functions 
which  are  the  most  involved  are  those  which  are  most  susceptible  to 
psychic  influence. 

The  digestive  function  has  always  seemed  to  us  to  be  the  one  on 
which  the  greatest  number  of  functional  manifestations  were  localized. 
With  it,  therefore,  we  shall  commence  our  study. 


CHAPTER  I. 

FUNCTIONAL  MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM. 

All  of  the  successive  acts  of  digestion  are,  to  a  certain  degree, 
started  going  by  an  antecedent  phenomenon,  which  at  the  outset  is 
apparently  peripheral,  but  which  is  accompanied  by  more  or  less  vivid 
mental  representations,  which  are  known  as  hunger  or  appetite.  It 
would  perhaps  be  useful,  in  order  to  be  exact,  to  make  a  distinction 
between  these  two  words,  hunger  and  appetite.  They  are  not  abso- 
lutely synonymous.  The  word  '^hunger"  expresses  some  sort  of  organic 
need  of  nourishment.  The  word  '  '  appetite  '  '  expresses  rather  the  psychic 
idea  of  nourishment.  One  can  have  an  appetite  without  being,  properly 
speaking,  hungry.  The  appetite  may  be  awakened  by  all  sorts  of  purely 
psychic  sensations,  such  as  an  odor,  a  savory  taste,  etc.,  ...  as  well  as 
association  of  ideas,  bearing  on  the  time,  or  on  places  which  recall  the 
idea  of  food,  and  lead  to  appetite.  As  a  matter  of  fact,  from  the  point 
of  view  which  interests  us,  the  two  terms  may  be  used  indifferently,  and 
the  only  thing  to  which  we  attach  importance  is  the  knowledge  that  if 
this  first  phenomenon  of  digestion  may,  so  to  speak,  be  an  outside 
appeal,  it  may  also  be  largely  dependent  upon  the  intervention  of  the 
psychic  mechanism. 

Disturbances  of  appetite  will  be  the  first  which  we  shall  pass  in 
review.  We  shall  then  study  a  whole  series  of  functional  manifestations, 
which  may  be  produced  at  different  stages  of  digestion. 

Disturbances  of  Appetite. 

These  disturbances  may  be  quantitative  or  qualitative.  We  shall 
take  up  successively: 

A.  Mental  anorexia.  Quantitative  disturbance  of  the  appetite  due 
to  lack  of  food. 

B.  Quantitative  disturbance  of  the  appetite  due  to  excess. 

C.  Elective  anorexias,  or  qualitative  disturbances  of  the  appetite, 

A.  Mental  Anorexia. — It  sometimes  happens  that  a  physician  has 
patients — they  are  more  apt  to  be  women — whose  appearance  is  truly 
shocking.  Their  eyes  are  brilliant.  Their  cheeks  are  hollow,  and  their 
cheek  bones  seem  to  protrude  through  the  skin.  Their  withered  breasts 
hang  from  the  walls  of  their  chest.  Every  rib  stands  out.  Their 
shoulder-blades  appear  to  be  loosened  from  their  frame.  Every  vertebra 
shows  through  the  skin.  The  abdominal  wall  sinks  in  below  the  floating 
ribs  and  forms  a  hollow  like  a  basin.  Their  thighs  and  the  calves  of 
their  legs  are  reduced  to  a  skeleton.  One  would  say  it  was  the  picture 
of"  an  immured  nun,  such  as  the  old  masters  have  portrayed.  These 
2 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.  3 

women  appear  to  be  fifty  or  sixty  years  old.  Sometimes  tiiey  seem  to 
be  sustained  by  some  unknown  miracle  of  energy;  their  voices  are 
strong  and  their  steps  firm.  On  the  other  hand,  they  often  seem  almost 
at  the  point  of  death,  and  ready  to  draw  their  last  breath. 

Are  they  tuberculous  or  cancerous  patients,  or  muscular  atrophies 
in  the  last  stages,  these  women  whom  misery  and  hunger  have  reduced 
to  this  frightful  gauntness?  Nothing  of  the  kind.  Their  lungs  are 
healthy,  there  is  no  sign  of  any  organic  affection.  Although  they  look 
so  old  they  are  young  women,  girls,  sometimes .  children.  They  may 
belong  to  good  families,  and  be  surrounded  by  every  care.  T^^ 
patients  are  what  are  known  as  mental  anorexics,  who,  without  having 
any  physical  lesions,  but  by  the  association  of  various  troubles,  all 
having  a  psychic  origin,  have  lost  a  quarter,  a  third,  and  sometimes  a 
half  of  their  weight.  The  affection  which  has  driven  them  to  this 
point  may  have  lasted  months,  sometimes  years.  Let  it  go  on  too 
long  and  death  will  occur,  either  from  inanition  or  from  secondary 
tuberculosis.  However,  it  is  a  case  of  nothing  but  a  purely  psychic 
affection  of  which  the  mechanisms  are  of  many  kinds. 

Sometimes  we  meet  individuals  afflicted  with  well-defined  character- 
istic psychoses  who  will  not  eat.  Such  are  the  melancholies  who  think 
they  can  commit  suicide  by  doing  without  food.  There  are  also  those 
with  persecutory  delusions,  who  are  overcome  by  the  fear  of  being 
poisoned.  Other  subjects,  such  as  the  major  deliria,  do  not  eat,  because 
their  delirium  is  sufficiently  intense  to  inhibit  —  temporarily  —  all 
peripheral  sensations.  All  these  patients,  once  the  delusional  idea  has 
disappeared,  are  able  to  be  fed  up  immediately,  and  in  an  intensive 
manner.  These  do  not  come  within  the  limits  of  our  study.  The 
mental  representation  of  appetite  is  neither  actually  nor  virtually  lost 
to  them. 

Neither  shall  we  consider  those  apparent  cases  of  mental  anorexia 
which  we  find  in  certain  hysterics  who  affect  anorexia  in  public,  but 
who  eat  on  the  sly. 

True  mental  anorexia  consists  in  the  progressive  loss  of  the  mental^ 
representation  of  appetite. 

For  the  moment  that  the  inhibition  of  the  psychic  phenomenon 
which  constitutes  appetite  is  accompanied  by  an  inhibition  of  the 
physical  phenomenon — ^which  is  the  feeling  of  bodily  hunger — mental 
anorexia  is  established. 

We  shall  study  under  the  name  of  secondary  mental  anorexia  those 
cases  where  the  taking  of  food  has  been  restricted  with  the  idea  of 
relieving  some  former  digestive  trouble.  We  shall  give  the  name  primary 
mental  anorexia  to  those  cases  in  which  originally,  and  often  volun- 
tarily, the  amount  of  food  taken  by  the  individual  had,  for  some  cause 
or  other,  been  diminished.  The  common  characteristic  of  all  these 
patients  is  that,  when  their  affection  has  reached  a  certain  stage,  they 


4      STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

get  to  the  point  where  if  they  should  want  to  eat  they  could  not,  for 
they  no  longer  have  any  feeling  of  hunger. 

In  primary  mental  anorexia  two  classes  of  facts  must  be  considered. 
Sometimes  the  loss  of  appetite  is  emotional  in  its  origin.  Sometimes 
the  reduction  of  food  has  been  purely  voluntary  at  the  start. 

Here,  for  example,  as  an  illustration  of  the  first  class,  is  the  case 
of  a  woman,  fifty  years  of  age,  who  has  been  a  widow  for  several 
months.  Her  children  live  at  some  distance  from  her,  and  are  not  of 
much  comfort  to  her.  Her  whole  life  was  wrapped  up  in  her  husband. 
She  is  extremely  thin.  She  weighs  seventy-nine  pounds,  instead  of 
her  normal  weight,  which  is  in  the  neighborhood  of  one  hundred  and 
ten  pounds.  This  loss  of  weight  has  been  rapid.  It  has  taken  place 
in  three  months.  She  says  she  is  actually  incapable  of  eating.  Her 
food  sticks  in  her  throat.  She  chews  it  indefinitely,  and  cannot  get  up 
courage  to  swallow  it.  An  ^g^,  two  or  three  cups  of  milk,  and  a  few 
mouthfuls  of  bread  are  her  daily  diet.  It  is  the  typical  picture  of 
mental  anorexia.  How  did  it  start?  Here  is  a  case  which  is  purely 
emotional  in  its  origin,  and  this  is  how  it  happened.  This  woman 
continued  to  occupy  the  apartment  where  she  had  lived  with  her  hus- 
band. When  she  sat  down  to  her  meals,  his  image  would  rise  before 
her,  as  would  be  natural  from  the  association  of  ideas,  bringing  a  whole 
train  of  emotional  sensations,  constriction  of  the  throat,  a  feeling  of 
weight  in  the  stomach,  lack  of  appetite,  etc.  She  would  get  up  from 
the  table  without  having  really  eaten  anjrthing.  By  degrees  this  re- 
striction of  diet  which  was  purely  emotional  in  its  origin  brought  her 
at  last  to  the  condition  of  mental  anorexia. 

Cases  of  this  kind  are  extremely  numerous.  Grief,  disappointment 
in  love,  or  unhappiness  in  marriage  are  very  often  the  emotional  source 
of  the  most  characteristic  mental  anorexias. 

In  other  cases  the  restriction  is  at  first  voluntary  and  intentional. 
It  is  often  due  to  coquetry. 

A  young  girl,  nineteen  years  of  age,  weighing  one  hundred  and 
forty-three  pounds,  thought  she  was  a  little  too  heavy,  so  she  tried 
to  grow  thin.  She  succeeded  in  losing  twenty  pounds  in  five  months. 
In  the  meantime  she  became  engaged.  Her  future  husband  thought 
she  was  too  thin  ;  so  she  tried  to  regain  all,  or  at  least  some,  of  her 
lost  weight,  but  her  efforts  were  useless.  She  could  no  longer  eat,  and 
she  continued  to  grow  thinner.  Her  previous  struggle  against  her 
appetite  had  caused  her  to  become  an  anorexic. 

Mysticism  is  responsible  for  a  great  many  cases  of  mental  anorexia. 
Regular  fasting,  instead  of  an  occasional  fast,  is  what  induces  it.  Here 
is  an  example  of  a  young  lady,  who  hitherto  had  had  no  psychopathic 
taint.  She  had  a  brother  who  in  several  months  was  to  come  up  for 
his  examination  in  a  great  government  school.  She  took  a  vow  that 
she  would  eat  nothing  but  the  smallest  portion  that  would  suffice  her. 


JVIANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.  5 

Being  very  scrupulous  she  observed  her  fast  qualitatively  as  well  as 
quantitatively.  The  brother  passed  his  examination  and  entered  the 
school,  and  the  young  girl  tried  to  eat  as  she  had  formerly  done.  But 
her  appetite  was  no  longer  there,  and  she  was  obliged  to  spend  several 
months  in  a  sanitarium  to  cure  the  mental  anorexia,  which  had  reduced 
her  to  the  last  degree  of  emaciation. 

Following  the  same  idea,  we  once  knew  of  a  young  man  who  in- 
tended to  enter  a  monastery.  Fearing  that  he  would  not  be  able  to 
stand  the  fasts  which  this  life  imposed,  and  yet  desirous  of  following 
his  call,  he  thought  that  he  would  make  a  sort  of  test,  and  put  himself 
through  some  privations  in  the  matter  of  food.  In  a  few  months  his 
efforts  were  rewarded  by  an  attack  of  mental  anorexia. 

This  case  is  similar  to  those  of  notable  fasters  who  some  years  ago 
made  a  regular  sporting  profession  of  fasting,  and  who  would  go  twenty 
or  thirty  days  without  eating. 

Finally  there  are  cases  of  mental  anorexia  whose  origin  is  wholly 
different.  This  anorexia  is  of  a  social  origin.  It  is  the  anorexia  of  poor 
people,  who  are  obliged  by  the  necessities  of  life  to  deprive  themselves 
to  such  a  degree  that,  when  the  illness  or  lack  of  employment  which 
has  caused  these  privations  has  disappeared,  they  find  it  impossible  to 
take  food  again. 

Patients  afflicted  with  primary  anorexia  have  this  special  character- 
istic, that  in  spite  of  their  extreme  thinness,  they  keep  a  good  deal  of  their 
strength.  We  have  seen,  in  illustration  of  this,  young  girls,  who  had 
gone  down  to  fifty-five  or  sixty-five  pounds  in  weight,  continuing  to 
live  as  their  friends  did,  going  for  long  walks  and  playing  tennis. 

Organically,  these  patients,  as  a  rule,  present  only  one  important 
symptom,  namely  the  suppression  of  the  menses. 

Secondary  mental  anorexia  differs  from  primary  mental  anorexia  in 
a  certain  number  of  ways.  First  of  all,  in  this  form  the  two  sexes 
may  be  equally  attacked,  while,  as  we  have  already  indicated,  primary 
mental  anorexia  is  found  chiefly  in  women.  In  secondary  mental 
anorexia,  while  the  clinical  picture  is  the  same,  as  far  as  the  loss  of 
weight  goes,  the  strength  of  the  patient,  on  the  contrary,  is  very  much 
less.  When  they  are  lying  down  they  are  hardly  able  to  raise  them- 
selves up.  This  is  because  it  depends  upon  disturbances  which  have 
taken  place  very  slowly.  The  alimentary  restriction  is  only  secondary. 
These  are  the  false  gastropaths  or  enteropaths  who,  either  spontaneously 
or,  alas,  more  often  by  reason  of  medical  prescriptions,  have  entered 
upon  a  very  strict  régime,  which  they  have  followed  only  too  well.  By 
reason  of  constantly  noticing  themselves  and  classifying  their  foods  and 
rejecting  all  kinds  that  they  think  they  cannot  digest,  they  finally 
manage  to  live  on  an  incredibly  small  amount.  Alimentary  phobias 
creep  in,  and  without  showing  any  other  intellectual  disturbances,  or 
any  other  modifications  of  character,  these  patients  become  rebellious, 


6      STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

or  make  a  great  scene  whenever  anyone  tries  to  make  them  eat.  There 
are  some  who  subsist  on  a  quarter  of  an  apple.  For  others  two  or  three 
prunes  form  their  daily  rations.  A  certain  one  took  two  or  three  eggs 
a  day.  We  saw  another  who  had  gotten  to  the  point  where  she  could 
live  if  she  had  a  bowl  of  sugar  water  beside  her.  She  dipped  a  paint 
brush  into  it  from  time  to  time,  and  moistened  her  lips  with  it.  This 
was  her  only  nourishment. 

There  are,  unfortunately,  only  too  many  examples  of  cases  where 
these  conditions  have  been  brought  about  by  dietary  regulations  pre- 
scribed by  some  ill-advised  physician.  These  patients,  in  fact,  will 
often  say  to  you,  ''  It  is  no  wonder  that  I  eat  so  little,  for  they  have 
steadily  cut  down  the  quantity  of  my  food  on  the  one  hand,  and  on 
the  other  hand,  they  have  put  me  on  a  diet  from  which  they  have  cut  out 
everything  I  like  to  eat.  '  ' 

A  young  girl,  eighteen  years  of  age,  who  had  undergone  much  grief 
and  emotion  and  anxiety,  lost  her  appetite.  A  physician  was  consulted, 
and  she  was  put  upon  a  diet,  thanks  to  which,  at  the  end  of  six  months, 
she  weighed  only  sixty-one  and  a  half  pounds. 

A  child  of  fourteen  who  had  lost  her  father  a  year  before,  and 
whose  mother  was  left  a  widow  with  four  children,  was  much  affected 
by  the  poverty  in  which  they  found  themselves.  She  developed  some 
digestive  troubles  of  whose  origin  the  physician  was  ignorant.  He 
reduced  her  diet  to  soups  and  milk  foods,  with  the  result  that  the  child 
faded  away  before  one's  very  eyes,  until  she  weighed  only  fifty  pounds. 

At  other  times  mental  anorexia  is  established  without  any  previous 
emotional  disturbance,  but  simply  by  ill-advised  medical  treatment.  A 
young  girl  of  nineteen  was  sent  to  us  from  the  provinces,  on  account 
of  her  excessive  loss  of  weight.  She  weighed  only  sixty-two  and  a 
half  pounds,  and  ate  nothing  but  a  little  fruit  and  an  egg  each  day. 
Until  six  months  before  she  had  been  hearty  and  well,  but  having  a 
sore  throat  she  was  put  upon  a  liquid  diet  that  was  far  from  sufficient. 
Her  appetite  gradually  disappeared,  and  in  three  months  she  had  lost 
forty-four  pounds. 

The  lack  of  recognition  of  mental  anorexia  is  all  the  more  serious 
because  patients  who  are  afflicted  by  it  may  die  of  inanition.  The 
pulse  then  becomes  very  rapid  and  respiration  difficult,  fetid  odors 
come  from  the  mouth,  and  some  patients  slip  away  who  could  certainly 
have  been  saved  by  better  treatment. 

One  of  us  has  seen  several  such  cases  of  death,  in  his  private  practice, 
as  well  as  in  the  hospital.  One  of  these  patients,  whom  he  saw  forty- 
eight  hours  before  she  died,  had  come  from  a  sanitarium,  where  she 
had  been  put  upon  a  restricted  diet. 

Secondary  mental  anorexia  occurs  at  all  ages  of  life;  but  primary 
mental  anorexia  is  more  apt  to  be  found  in  young  girls  from  fifteen 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.  7 

to  twenty  years  of  age,  though  it  may  occur  much  earlier  or  much 
later. 

Nobecourt  first  and  then  Aynaud  have  studied  the  modifications 
which  the  blood  undergoes  in  anorexics  during  the  development  of 
their  affection,  and  during  the  period  when  they  begin  to  take  nourish- 
ment again.  At  the  entry  of  a  certain  patient  to  one  of  our  services, 
Aynaud  found  5,000,000  red  corpuscles  and  a  normal  percentage  of 
hemoglobin.  But  this  blood  formula  is  only  apparently  normal  in 
consequence  of  the  concentration  of  the  serum.  After  this  patient  had 
been  for  three  days  upon  a  forced  milk  diet,  thé  red  corpuscles  were 
only  2,800,000  and  60  per  cent,  haemoglobin.  The  same  patient,  who 
at  her  entrance  showed  a  certain  degree  of  leucopaenia,  had  a  little 
later  12-15,000  white  corpuscles,  and  later  still,  w^hen  her  menses 
returned,  a  trace  of  eosinophilia. 

In  the  same  patients,  the  condition  of  the  gastric  juice  has  been 
examined.  It  has  been  found  at  times  normal,  and  at  times  hypo- 
chlorhydric,  which  in  itself  explains  the  lack  of  desire  for  food. 

A  frank  case  of  mental  anorexia  can  be  easily  recognized  by  any 
physician  who  is  at  all  informed.  Nevertheless,  we  have  found  many 
severe  cases  of  anorexia  that  were  nursed  along  and  aggravated  in  their 
anorexia,  by  physicians  who  were  exaggeratedly  devoted  to  dietetics 
and  physical  treatment. 

On  the  other  hand,  mental  anorexias  that  are  in  process  of  develop- 
ment are  very  seldom  recognized,  and  there  is  an  incalculable  number 
of  pseudo-dyspeptics  and  false  gastropaths  who  by  virtue  of  medical 
prescriptions  are  slipping  gently  into  mental  anorexia,  without  anyone 
doing  anything  to  stop  them  on  their  dangerous  way.  We  shall  come 
across  these  patients,  later  on,  in  studying  the  different  functional 
troubles  which  are  connected  with  the  digestive  system. 

Mental  anorexia  is  perhaps  the  most  serious  of  all  the  functional 
manifestations,  for  it  endangers  the  patient's  life  in  two  ways;  either 
incidentally,  by  diminishing  his  resistance  to  any  organic  disease  which 
may  attack  him — particularly  tuberculosis — or  the  mental  anorexia  itself 
may  cause  death.  One  can  hardly  realize,  in  fact,  the  condition  of 
cachexia  to  which  these  patients  may  be  reduced.  Their  emaciation  is 
frightful.  We  have  seen  loss  of  weight  running  from  forty-four  to 
sixty-six  pounds,  and  patients  who  normally  weighed  one  hundred  and 
ten  pounds  or  more  were  reduced  to  a  weight  of  sixty-six,  sixty-one, 
and  fifty-five  pounds.  We  have  even  seen  examples  of  patients  who 
have  lost  half  their  bodily  weight.  When  this  limit  is  passed,  in  spite 
of  all  treatment,  the  case  is  generally  hopeless.  The  near  approach  of 
death  is  generally  heralded  by  the  fetid  odor  given  off  by  the  patients 
and  by  tach^^cardia  and  dyspnoea. 

But  there  is  no  absolute  and  distinct  sign  by  which  one  can  dis- 
tinguish the  patient  who  cannot  recover  from  the  one  who  will  respond 


8      STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

to  treatment.  We  know  patients  who  have  reduced  their  food  to  a 
few  teaspoonfuls  of  café  au  lait,  and  who  had  lost  half  their  weight, 
but  who,  nevertheless,  were  cured.  The  anorexic  who  is  cured  regains 
her  health  completely;  and  in  women  the  reappearance  of  the  menses 
constitutes  an  important  sign  of  cure.  When  carefully  treated,  accord- 
ing to  the  general  treatment  of  neuropaths,  which  we  shall  take  up 
later,  there  is  no  danger  of  a  relapse. 

But  badly  treated,  they  may  recover  temporarily,  but  a  relapse  is 
almost  fatal.  When  such  a  relapse  takes  place  soon,  the  loss  of  weight 
is  much  more  rapid  than  it  was  in  the  case  of  the  first  attack.  This 
is  easily  explained  by  the  fact  that  the  patient's  reserve  force  lies 
chiefly  in  fat. 

To  sum  up,  whether  incipient  or  established,  mental  anorexia  is  a 
fact  of  frequent  occurrence.  It  is  an  affection  which  no  physician  has 
the  right  to  let  pass  unrecognized.  Whether  he  mistakes  established 
anorexics  for  patients  with  an  organic  disease  and  treats  them  with 
medicine,  or  whether  he  permits  an  undeveloped  anorexia  to  become 
estabhshed,  he  is  equally  to  blame  ;  for  anorexics  respond  beautifully  to 
treatment,  while  the  failure  to  recognize  such  an  affection  leads  more 
or  less  directly  and  more  or  less  rapidly  to  the  death  of  the  patient. 

The  diagnosis  of  mental  anorexia  is  extremely  simple.  It  merely 
requires  thought.  It  only  becomes  complicated  when  the  mental 
anorexia  is  grafted  on  to  a  true  organic  disease.  But  even  in  these 
cases  the  history  guides  you,  and  every  time  that  you  find  that  the 
patient  has  gone  upon  a  restricted  diet,  either  voluntarily  or  from 
some  emotional  cause,  and  this  has  been  followed  by  a  loss  of  the 
psychic  idea  of  appetite,  you  can  safely  assume  the  existence  of  mental 
anorexia,  either  pure  and  simple  or  associated  with  something. 

B.  Quantitative    Disturbances   of   the   Appetite   due   to   Excess. 

— Neither  the  cravings  of  hunger  in  some  psychoses,  nor  the  true 
defensive  processes  which  constitute  the  polyphagia  of  diabetics  or 
convalescents,  come  within  the  scope  of  our  study.  It  is  a  wholly 
different  class  of  cases  which  we  wish  to  describe.  In  these,  psychic 
hunger  corresponds  no  more  to  organic  hunger  than  it  does  in  the 
case  of  a  diabetic.  The  appetite  is  purely  psychic.  It  is  created  by 
a  mentg,!  systematization  of  such  a  nature  that  mental  images  con- 
nected with  the  taking  of  food  are  awakened,  and  lead,  as  it  were,  to  a 
false  mental  hunger  which  is  quite  analogous  to  the  false  hunger  de- 
scribed in  certain  organic  diseases,  where  the  sensation  of  hunger  is 
aroused  by  the  repetition  of  peripheral  stimuli,  as  it  is  in  our  patients 
by  the  repetition  of  psychic  stimuli.  Such  cases  are  evidently  much 
rarer,  and  much  less  apparent,  as  well  as  much  less  serious,  than  the 
cases  of  mental  anorexias. 

They  deserve,  nevertheless,  to  be  noticed,  on  account  of  their 
mechanism.     As  a  rule  the  psychic  orientation  of  the  subject  is  of  a 


JVIANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.  9 

purely  medical  origin.  These  are  individuals  who  have  been  con- 
vinced of  the  necessity  of  taking  many  and  frequent  meals.  We  have 
seen  neurasthenics  of  this  order  who  have  been  convinced  that  they 
could  not  dare  to  take  even  a  short  walk  without  carrying  with  them 
some  refreshment  to  sustain  them,  and  enable  them  to  continue  the 
effort.  Under  the  influence  of  this  psychic  orientation,  these  patients, 
if  they  are  not  provided  with  their  customary  daily  lunch,  are  some- 
times seized  with  a  veritable  obsession  of  hunger,  which  forces  them  to 
retrace  their  steps  in  order  to  get  their  forgotten  food. 

In  other  cases  we  have  to  do  with  individuals  who  at  some  previous 
time,  and  for  a  definite  reason,  have  been  overfed,  and  who,  when 
the  forced  feeding  is  no  longer  necessary,  and  even  when  they  are 
persuaded  that  it  is  not  so,  cannot  return  to  a  normal  régime,  some- 
times for  months,  and  sometimes  even  for  years.  We  have  been  able 
to  follow  certain  patients  of  this  kind  who  have  continued  to  experi- 
ence very  lively  sensations  of  excessive  hunger  fully  fifteen  and  twenty 
years  after  a  treatment  of  overfeeding — for  pulmonary  tuberculosis, 
for  instance. 

Furthermore,  in  certain  individuals,  a  sensation  of  hunger  being 
produced  under  normal  conditions  assumes  an  intensity  which  is  wholly 
out  of  the  ordinary.  We  are  reminded  here  of  the  case  of  a  young 
man  who,  in  order  to  enter  upon  a  certain  career,  was  obliged  to  go 
without  his  early  breakfast.  Now,  each  time  that  he  tried  to  do  with- 
out this  slight  meal,  he  was  seized  with  sensations  of  hunger,  that 
were  so  acute  that  they  amounted  almost  to  faintness.  On  analyzing 
it,  it  proved  to  be  a  case  of  an  intense  exaggeration  of  the  sensation 
of  hunger,  under  the  influence  of  purely  psychic  phenomena.  The 
anxiety  Which  the  patient  felt,  lest  he  be  obliged  to  give  up  his  career 
by  reason  of  his  not  being  able  to  change  his  régime,  was  the  only 
cause  of  it.  It  was  so  entirely  the  cause  that,  once  the  young  man 
was  assured  of  it,  he  was  cured  in  several  days,  and  could  easily 
accommodate  himself  to  this  slight  irregularity  in  his  habits  of  eating. 

These  cases  are  often  rather  difficult  to  analyze,  and  such  manifesta- 
tions must  not  be  confused  with  the  phenomena  which  are  found  in 
certain  subjects,  such  as  congenital  neuropaths,  in  whom  the  fear  of 
not  being  able  to  follow  the  treatment  laid  down  for  them  fully  or 
conscientiously  enough  becomes  the  starting  point  of  an  obsession  or  a 
scruple.  Here  there  is  nothing  of  the  kind.  Our  patients  feel  a  very 
real  hunger  starting  from  within,  but  accompanied  by  the  whole  series 
of  sensations  of  taste  and  salivary  phenomena,  which  they  would  ex- 
perience as  the  normal  consequences  of  the  sensation  of  hunger.  More- 
over, the  purely  psychic  nature  of  these  phenomena  is  further  demon- 
strated by  their  rapid  disappearance  under  appropriate  treatment. 

However  it  may  be,  one  fact  remains  patent,  and  that  is  that 
under  the  influence  of  association  of  ideas,  of  psychic  convictions,  or 


10  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

mental  interpretations,  it  is  possible  for  acute  sensations  of  hunger  to 
arise,  and  to  be  accompanied  by  aU  the  physical  peripheral  reactions, 
both  normal  and  abnormal,  which  such  a  sensation  is  liable  to  produce. 
Let  us  call  attention,  on  the  other  hand,  to  the  existence  of  sudden 
attacks  of  real  hunger,  following  some  more  or  less  lively  emotion, 
and  which  are  brought  back  upon  the  repetition  of  the  emotion.  We 
have  never  seen  such  phenomenon  give  rise  to  persistent  troubles  of 
the  kind  which  we  have  just  been  considering;  but  we  shall  not  dwell 
upon  this,  but  will  now  pass  to  another  kind  of  digestive  trouble. 

C.  Elective  Anorexias. — When,  just  now,  we  were  studying  the 
mental  anorexias,  we  found  many  patients  who  refused  vaguely  to  try 
any  food  whatsoever.  This  is  by  no  means  the  same  affection,  and  is 
infinitely  less  serious  ;  in  fact,  the  subjects  which  we  really  have  in  mind 
may  get  food  in  a  variety  of  ways,  but  though  there  is  no  longer  a 
quantitative  restriction,  there  is  a  qualitative  restriction  in  their  food. 

Mr.  M.,  fifty  years  of  age,  a  manufacturer,  having  had  numerous 
business  perplexities,  a  family  to  provide  for,  and  a  sick  wife,  was  at 
a  certain  time  attacked  by  gouty  symptoms.  His  physicians  conceived 
the  idea  of  putting  him  upon  an  absolute  milk  diet.  He  stood  the  treat- 
ment remarkably  well.  But  when  the  symptoms  had  disappeared  and 
the  patient  was  advised  to  return  to  a  normal  diet,  it  was  absolutely 
impossible.  With  every  other  food  except  milk  the  patient  acted  like 
a  true  •  anorexic.  He  would  chew  his  meat  and  vegetables  indefinitely, 
and  would  swallow  them  with  the  greatest  difficulty.  In  fact,  the 
attempt  to  go  back  to  a  normal  diet  resulted  in  a  very  rapid  and  con- 
siderable loss  of  flesh,  so  that  after  having  lost  twenty  pounds  the 
patient  returned  to  his  strictly  milk  diet. 

In  the  psychological  analysis  of  the  case,  it  was  brought  out  that 
the  patient  for  whom  the  milk  diet  had  succeeded  so  well,  either  from 
causal  relations  or  by  simple  coincidence,  was  afraid  that  by  going  back 
to  his  normal  food  he  would  again  experience  his  gouty  symptoms, 
and  in  consequence  his  commercial  activity  would  be  interrupted.  Hence 
the  phenomena  observed.  This  patient  was  treated  by  one  of  us  only 
for  a  very  short  time,  in  the  course  of  which  it  was  impossible  to  make 
him  take  any  solid  food  whatsoever.  On  last  hearing  from  him  the 
patient  was  still  upon  a  strictly  milk  diet,  and,  not  finding  himself  any 
the  worse  for  it,  absolutely  refused  to  try  to  go  back  to  more  normal 
nourishment. 

For  the  same  reason  we  often  find  people  giving  up  certain  dishes 
which  have  disagreed  with  them,  though  perhaps  it  was  mere  coin- 
cidence. Thus  regular  food  phobias  are  created.  We  shall  find  plenty 
of  them  in  studying  the  large  and  complex  group  of  false  gastropaths. 
Certain  people,  who  are  able  to  digest  food  which  is  supposed  to  be 
extremely  indigestible,  will  reject  from  some  purely  psychic  cause 
such  and  such  a  dish,  for  which  after  a  time  they  acquire  a  feeling  of 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         11 

positive  disgust,  which  will  bring  on,  simply  by  a  mental  attitude,  the 
most  varied  disorders. 

There  are  other  disturbances  of  appetite  which  frequently  depend 
upon  purely  psychic  phenomena,.  The  capricious  appetite  which  is  so 
common  among  young  girls  and  young  women,  may  often  be  psychic 
or  emotional  in  its  origin.  We  could  cite  numerous  examples  of  such 
cases. 

In  fact,  it  is  a  very  common  thing  to  find  that  the  sensation  of 
appetite  is  susceptible  to  modifications  of  degree  and  in  kind,  accord- 
ing to  the  patient's  psychic  condition.  Either  a  definite  mental  repre- 
sentation or  an  emotion  is  capable  of  inhibiting  a  phenomenon  which 
is  normally  purely  reflex.  This  is  the  ultimate  conclusion  to  which  we 
are  led  by  the  study  of  this  first  series  of  functional  manifestations. 

Disturbances  closely  allied  to  those  we  have  just  been  considering 
are  developed  by  neuropathic  modifications  of  thirst.  To  avoid  un- 
necessary repetition,  we  shall  study  these  disturbances  when  we  take 
up  the  subject  of  the  modification  of  the  amount  of  urine  in  connection 
with  the  psychoneuroses. 

Functional  Digestive  Manifestations  Properly  So-called. 

Normal  physiology  recognizes  a  certain  number  of  steps  in  the 
process  of  digestion,  which  are  as  follows: 

The  taJdng  of  food;  buccal  ddgestion;  mechanical  and  secretory 
phenomena  {mastication  and  salivation);  passage  through  the  pharynx 
and  oesophagus;  deglutition;  stomach  digestion;  passage  through  the 
pylorus;  intestinal  digestion;  passage  through  the  ileocœcum;  cœco- 
colon  digestion;  defecation. 

There  is  no  one  of  these  stages  which  may  not  be,  either  directly 
or  indirectly,  influenced  by  neuropathic  phenomena.  For  convenience 
in  description,  and  because  such  a  division  corresponds  better  with  the 
clinical  types,  we  shall  study  them  in  four  distinct  chapters  as  follows: 

A.  Functional  disturbance  of  the  first  three  siages  of  digestion. 

B.  Gastric  disturbances  in  nervous  patients;  a  study  which  we  have 
already  taken  up  in  previous  works  ("False  Oastropaths  and  False 
Gastropathies,''  1906). 

C.  Functional  modifications  in  elimination.  Nervous  diarrhœa  and 
nervous  constipation,  and  their  consequences. 

D.  Intestinal  modifications  properly  so-called. 

A.  Functional  Disturbances  of  the  First  Three  Stages  o£ 
Digestion. — An  educated  man  of  thirty-eight  years  of  age,  well  in- 
formed in  medical  matters,  and  formerly  syphilitic,  had  seen  several 
persons  of  his  acquaintance  die  of  general  paresis.  He  knew  that 
difficulty  in  speech,  trembling  of  the  tongue,  and  trouble  in  swallowing 
were  frequently  in  the  list  of  symptoms  of  the  disease  with  which  he 
more  and  more  believed  himself  to  be  threatened.    From  that  time  on 


12  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

he  examined  his  mouth  and  his  tongue  many  times  a  day.  Soon  he 
thought  he  felt  a  certain  stiffness  in  the  muscles  of  his  face  and  cheeks. 
He  continually  made  chewing  movements,  and  it  seemed  to  him — to 
use  his  own  words — that  he  had  a  piece  of  rubber  in  his  mouth.  All 
these  movements  could  not  help  but  stimulate  an  excessive  flow  of 
saliva,  which  rendered  his  speech  somewhat  difficult.  He  constantly 
had  bubbles  in  his  mouth.  It  was  not  long  before  difficulty  in  swallow- 
ing made  its  appearance.  All  these  disturbances  were  purely  phobic 
in  their  nature.  The  patient  did  not  dare  to  swallow.  He  chewed  his 
food  a  long  time  before  making  an  effort  to  swallow,  and  in  this  way, 
by  progressive  auto-suggestion,  there  was  created  a  characteristic  syn- 
drome of  difficulty  of  mastication,  rather  abundant  salivation,  and 
slowness  in  the  act  of  swallowing,  to  which  were  added  some  speech 
disturbances  which  we  shall  meet  with  elsewhere. 

Analogous  syndromes  are  formed  under  the  influence  of  incidents 
fixed  in  the  mind  of  the  patient.  A  workman,  an  engraver,  came  in 
March,  1909,  to  consult  one  of  us.  He  was  a  bachelor  thirty  years  of 
age,  of  an  emotional  temperament,  but  who  had  never  had  any  extrinsic 
emotional  cause  leading  up  to  the  development  of  his  symptoms.  He  came 
to  us  in  a  very  emaciated  condition,  having  lost  forty  pounds,  and  de- 
claring that  he  could  no  longer  swallow  anything  except,  with  the 
greatest  difficulty,  a  little  milk  and  bread  which  had  been  soaked  a  long 
time  in  it.  Six  months  before  he  had  accidentally  swallowed  something 
the  wrong  way.  The  fact  was  trivial,  but  the  patient  had  been  so  pain- 
fully affected  that  from  that  time  he  had  not  dared  to  swallow.  Every 
time  that  he  took  a  mouthful  that  was  a  little  larger  than  usual  he  thought 
that  the  same  thing  would  happen  again,  hence  his  condition  of  growing 
apprehension — augmented  rather  by  a  local  treatment  which  a  physician 
had  made  him  undergo,  whereby  progressive  restriction  of  food  was 
brought  about  and  the  patient  was  reduced  to  the  point  where  he  was 
when  he  was  seen  at  the  Salpêtrière.  There  we  made  him  eat  small  meals 
with  one  of  us  present.  At  first  it  took  him  several  hours  to  eat  what 
another  person  would  have  consumed  in  several  minutes.  Before  making 
up  his  mind  to  swallow,  he  would  chew  for  a  very  long  time.  Then  he 
would  stop  for  a  while,  and  one  would  see  him  as  if  hesitating  before 
swallowing.  He  would  thus  start  chewing  three  or  four  times  before  be- 
ing able  to  make  up  his  mind.  Under  these  conditions  a  state  of  volun- 
tary contraction  was  produced  in  the  region  of  his  pharynx  which 
made  swallowing  painful.  This  was  the  reason  that  the  affection  con- 
tinued, though  it  was  also  encouraged  by  various  suggestions  of  a  medical 
nature. 

In  this  particular  case  the  patient,  who  quickly  exhausted  his  powers 
of  salivation,  by  his  prolonged  mastication,  complained  of  dryness  of 
the  mouth  in  connection  with  eating,  and  was  obliged  to  drink  very 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         13 

often  and  in  rather  large  quantities,  in  order  to  get  through  his  meal. 
This  patient  was  cured  in  a  few  days. 

We  have  had  occasion  to  see  an  absolutely  identical  series  of  symp- 
toms in  the  case  of  a  factory  worker.  His  emaciation  was  so  extreme, 
that  at  first  sight  one  would  have  taken  him  for  a  case  of  organic  disease. 
He  had  gone  down  to  a  weight  of  one  hundred  and  eight  pounds  from 
a  normal  weight  of  one  hundred  and  sixty-five  pounds.  The  cause  in 
his  case  was  slightly  different.  One  day  he  had  swallowed  a  mouthful 
that  was  a  little  too  large,  which  had  gone  down  with  difficulty,  and 
not  without  causing  him  some  twinges  of  pain  and  a  transitory  spasm 
of  the  oesophagus. 

Here,  on  the  other  hand,  is  a  history  of  a  young  woman  thirty-seven 
years  of  age,  who,  at  the  age  of  twenty-one,  after  a  year  of  married 
life,  was  left  a  widow  with  a  child.  She  had  promised  her  husband 
at  his  death-bed  never  to  re-marry.  The  struggle  with  herself,  which 
she  had  gone  through  in  order  to  keep  this  promise,  had  made  her 
exaggeratedly  emotional. 

One  day,  while  eating  fish,  she  swallowed  a  bone  which  stuck  in 
her  throat.  They  sent  for  a  physician,  who  was  not  able  to  find  the 
offending  object  until  after  repeated  efforts.  The  impression  had  lasted 
long  enough  to  become  fixed,  and  the  patient,  becoming  dysphagic, 
had  gotten  to  the  point  where  it  took  her  five  or  six  hours  a  day  to 
swallow  the  smallest  quantity  of  liquid.  This  condition  lasted  for 
seven  years,  and  the  woman  was  really  in  a  cachectic  state.  Her  symptoms 
disappeared  in  a  few  weeks. 

A  patient  in  comfortable  circumstances  furnished  us  an  example 
of  analogous  phenomena,  called  into  existence  by  a  rather  different 
mechanism.  While  she  was  at  the  table  she  arose,  and  her  brother, 
in  fun,  seized  her  by  the  throat  to  make  her  sit  down.  She  swallowed 
the  wrong  way.  She  was  afflicted  with  trouble  in  swallowing  for 
seven  months.  She  could  only  manage  with  the  greatest  difficulty  to 
swallow  purées  and  liquids,  and  her  meals  took  an  infinitely  long  time. 
In  six  months  she  had  lost  twenty-four  pounds.  We  must  add  that  in 
her  case  her  emotionalism  was  caused  by  material  anxiety  and  unhappy 
conjugal  relations,  and  that  the  underlying  cause  of  this  particular 
symptom  was  the  fact  that  she  had  read  in  one  of  her  children's 
books,  the  statement  that  one  could  be  in  danger  of  choking  to  death 
if  one  swallowed  the  wrong  way. 

There  are  other  cases  of  patients  who,  by  swallowing  a  liquid  that 
was  too  hot,  which  slightly  burned  their  throats,  had  got  the  idea  into 
their  heads  for  months  that  nothing  could  go  down  their  oesophagus 
€xcept  liquids  or  broths. 

Spasm  of  the  oesophagus  is  caused  by  a  mechanism  analogous  to 
these.  As  a  pure  and  isolated  sjonptom  it  is  very  rarely  found,  and  the 
patients  whom  we  have  been  able  to  study  are  much  more  apt  to  have 


14  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

the  syndrome  which  we  have  just  described,  due  to  one  of  the  following 
causes:  An  accidental  phenomenon  in  the  region  of  the  pharynx  or 
oesophagus  ;  a  secondary  psychic  fixation  ;  consecutive  phobias  which  are 
partly  real,  os  a  result  of  fixing  the  attention  upon  phenomena  which 
are  usually  automatic. 

Disturbances  of  the  same  kind  may  occur  by  a  very  curious 
mechanism.  They  occur  in  individuals  who  are  troubled  with  slight 
rhinopharyngitis  with  granulations  of  the  throat,  and  who  have  been 
treated  by  cauterization,  or  by  repeated  applications,  and  who  thus 
have  their  attention  continually  directed  to  the  region  of  their  pharynx. 
They  are  always  thinking  about  their  swallowing,  and  finally  get  to  the 
point  where  they  experience  in  different  degrees  the  whole  series  of 
symptoms  which  we  have  just  described. 

It  seems  to  us  that  by  an  analogous  mechanism  might  be  explained 
in  many  cases  that  peculiar  trouble,  which  may  be  fraught  with  various 
consequences.  We  refer  to  aërophagia  or  air-swallowing.  This  difficulty 
is  developed  in  proportion  to  the  number  of  movements  in  swallowing, 
each  movement  bringing  with  it  a  certain  quantity  of  air,  especially 
when  one  swallows  nothing,  so  to  speak,  on  top  of  a  mouthful  of  food 
or  a  very  small  quantity  of  liquid. 

It  occurs  in  subjects  who  have  their  attention  slightly  but  not 
intelligently  focussed  on  their  pharynx.  To  this  class  of  individuals, 
in  particular,  belong  those  patients  so  well  known  to  all  physicians  who 
cannot  swallow  pills  or  capsules.  The  patients  continually  swallow  their 
saliva  and  thus  create  a  type  of  interprandial  aërophagia,  that  is  to 
say  they  develop  their  trouble  between  meals.  But  there  are  also  in 
certain  individuals  similar  difficulties  which  spring  from  another 
mechanism,  identical  to  that  which  creates  these  troubles  we  have  de- 
scribed above.  Following  any  accident  whatsoever  to  the  act  of  swallow- 
ing, these  people,  instead  of  not  daring  to  swallow  at  all,  no  longer  dare 
to  take  normal  mouthfuls.  They  will  only  swallow  very  small  quantities 
at  one  time,  and  thus  the  whole  series  of  aërophagic  phenomena  are 
developed  in  them.  Aërophagia,  as  one  knows,  makes  itself  worse,  and 
the  expulsion  of  gas  often  leads  to  the  swallowing  of  a  larger  quantity 
of  air. 

We  shall  meet  these  patients  again  further  on,  amid  the  false 
gastropaths,  whose  study  we  shall  now  take  up. 

B.  Gastric  Symptoms  in  Nervous  Patients. — Gastric  disturbances 
are  so  common  among  nervous  people,  and  particularly  among  those 
suffering  from  neurasthenia,  that  they  have  come  to  be  considered  an 
integral  part  and  almost  as  a  necessary  element  of  the  symptomatology. 
In  reality  it  would  not  be  fair  to  make  such  a  sweeping  generalization, 
for  there  are  very  many  neurasthenics,  who,  to  tell  the  truth,  however, 
fix  their  attention  on  some  other  part  of  their  body,  but  whose  digestive 
tract  is  in  admirable  condition.     Nevertheless,  gastric  troubles  are  ex- 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.  15 

tremely  frequent,  and  need  to  be  studied  very  carefully  in  detail,  because 
their  mechanism  is  extremely  varied. 

In  the  long  nomenclature  of  gastric  semiology,  there  is  no  objective 
or  subjective  symptom  but  that  can  be  felt  by  a  nervous  patient,  with- 
out any  real  organic  affection  to  cause  it. 

Symptoms  may  be  found  in  them  which  are  evidently  objective,  such 
as  nausea,  or  even  vomiting,  as  well  as  symptoms  of  true  dilatation  of 
the  stomach  closely  corresponding  to  those  of  a  very  real,  although 
purely  neuropathic  distention. 

Semi-objective  signs  of  various  natures,  such  as  pain  caused  by  pres- 
sure, and  finally  the  whole  gamut  of  subjective  sensations,  from  a  simple 
feeling  of  heaviness  to  the  most  acute  burning  sensation,  may  very 
frequently  be  observed. 

The  pathogeny  of  all  these  troubles  is  varied.  A  part  is  played  by 
real  modifications  of  the  gastric  secretion,  following  anorexia,  which 
suppresses  the  juice  psychically,  according  to  the  mechanism  which  Paw- 
low  has  demonstrated. 

Diminution  of  the  tonicity  of  the  gastric  muscle,  which  in  exhausted 
and  emaciated  neurasthenics  is  present  in  their  stomachs  in  exactly  the 
same  way  as  it  is  in  the  muscles  of  their  limbs,  and  aërophagia,  which 
often  occurs  in  neuropaths,  these  are  the  factors — in  a  way  organic 
though  of  nervous  origin — which  determine  a  number  of  the  troubles 
experienced. 

The  part  which  the  psychism  plays  is  none  the  less  important.  It 
results  entirely  from  the  patient  settling  his  attention  on  his  stomach, 
and  on  his  digestive  functions.  Sometimes  the  patient's  attention  is 
drawn  to  his  stomach  by  some  passing  difficulty,  following  too  hearty 
a  meal  ;  sometimes  it  is  a  gastric  trouble,  such  as  those  that  occur  in 
the  later  stages  of  pregnancy,  which  fi:x:es  the  patient's  psychism;  some- 
times it  is  the  loss  of  several  pounds  weight  following  excessive  physical 
exertion,  such  as  night  vigils,  etc.,  which  draws  the  attention  of  the 
patient  to  his  functions  of  nutrition;  sometimes,  again,  it  is  through 
articles  in  the  newspaper,  or  advertisements  of  pharmaceutical 
preparations  ;  sometimes,  and  much  more  often,  it  is  medical  advice  that 
has  given  impetus  to  a  series  of  phenomena  which  by  mechanism  of  self- 
or  outside-suggestion  will  go  on  developing  themselves.  A  line  of 
treatment  has  been  laid  down,  medicines  prescribed,  and  examinations 
made  which  have  centred  the  patient's  attention  upon  his  digestive 
tract,  and  which  keep  him  by  reason  of  medical  direction  in  a  con- 
tinual state  of  self-observation.  In  fact,  it  is  possible  to  start  up  a 
false  gastropathy  every  time  that  a  patient,  for  real  or  for  fancied 
reasons,  has  had  his  attention  directed  to  his  stomach.  Then  one  may 
see  the  development  of  a  very  interesting  phenomenon,  namely  that  each 
examination,  each  consultation,  each  new  prescription,  starts  up  some 
aggravation,   or  some   extension  of  the  troubles   observed.     At  other 


16  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

times,  and  it  not  infrequently  happens,  it  is  an  emotion,  and  especially 
a  repeated  emotion,  which  clutches  the  throat,  makes  one's  stomach 
feel  like  lead,  and  takes  away  one's  appetite,  and  which  serves  not 
only  as  a  starting  point,  but  as  a  means  of  development  by  reason  of 
the  bodily  sensations  which  it  creates. 

The  influence  of  the  morale  on  the  functions  of  the  stomach  is 
commonly  accepted.  Everyone  knows  that  when  he  is  in  a  temper  or 
has  a  sin  on  his  soul  his  appetite  falls  off,  and  his  digestion  is  bad. 
Yet,  notwithstanding,  physicians  have  never  properly  recognized  the 
importance  of  this  fact. 

But  now  let  us  take  a  case  where  there  are  real  gastric  disturbances^ 
following  nervous  troubles,  occurring  in  some  region  connected  with 
the  digestive  tract,  such,  for  instance,  as  constipation.  As  to  the  per- 
sistence and  the  encouragement,  so  to  speak,  given  to  digestive  mani- 
festations in  nervous  patients  outside  of  all  foreign  intervention,  they 
come  from  a  psychological  mechanism,  which  seems  very  simple  to  us. 
As  a  matter  of  fact  the  digestive  function  holds  a  leading  place  in  our 
physical  life,  not  only  from  the  point  of  view  of  its  importance,  but 
also  as  to  the  time  it  occupies.  It  is  psychically  associated  with  a  whole 
series  of  ideas  and  perceptions.  The  day  is  laid  out  according  to 
meal-times,  certain  rooms  of  the  house  are  given  over  to  the  preparation 
or  consumption  of  food.  One  is  obliged  to  order  meals,  and  to  plan  one 's 
life  by  them  in  such  a  way  that  the  number  of  ideas  which  are  asso- 
ciated with  the  digestive  functions  is  very  considerable;  and  once  a 
digestive  systematization  is  created  in  a  patient,  the  facts  and  impres- 
sions of  the  day  will  continually  serve  to  re-create  or  reinforce  it. 

Ketuming  to  the  classification  which  we  have  already  adopted,  we 
shall  study  successively  : 

1.  Simple  dyspepsias  of  neurasthenics. 

2.  Gastric  phobias. 

3.  Characteristic  pseudo-gastropathies. 

Finally  a  chapter  will  be  devoted  to  the  study  of  : 

4.  Dilatation  of  the  stomach  in  nervous  patients. 

5.  Vomiting  as  a  neuropathic  manifestation. 

1.  Simple  Dyspepsias  of  Neurasthenics. — Appetite,  if  we  are  to  be- 
lieve the  teachings  of  modem  physiology,  is  the  best  stimulant  to 
digestion.  The  neurasthenic  is  never  hungry;  therefore,  he  digests 
badly.  As  a  matter  of  fact,  the  sensation  of  slow  and  difficult  digestion, 
with  a  heavy  feeling  after  meals,  is  very  frequent  in  neurasthenics. 
Digestive  disturbances  have  their  objectivity  in  the  active  modifications 
of  the  gastric  functions,  but  are  none  the  less  pathogenically  and 
therapeutically  of  a  purely  psychopathic  nature.  Their  mechanism  lies 
in  a  very  mild  form  of  mental  anorexia,  to  which  the  majority  of 
neurasthenics  are  subject. 

As  for  this  anorexia  itself,  several  elements  combine  to  create  it.    The 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         17 

act  of  taking  food  requires,  in  fact,  some  effort,  and  one  knows  how 
distasteful  effort  is  to  the  neurasthenic,  whether  it  be  intellectual, 
physical,  or  alimentary  in  its  nature.  The  bother  of  getting  himself 
fed  starts  an  anorexia,  and  that  kind  of  anorexia  which  especially 
avoids  all  kinds  of  foods  which  would  require  any  kind  of  effort  to 
prepare  or  eat.  Very  frequently,  on  the  other  hand,  the  neurasthenic 
is  obsessed  or  preoccupied  with  some  idea.  Obsessions  and  preoccupa- 
tions are  in  themselves  capable  of  neutralizing  to  some  degree  the 
sensations  of  physical  life,  among  which  the  sensation  of  appetite 
occupies  a  place  in  the  front  rank.  Very  frequently,  moreover,  obses- 
sions and  preoccupations  act  by  the  intervention  of  a  state  of  unin- 
termittent  emotions  which  they  occasion,  leading  to  a  whole  series  of 
impressions  which  take  away  the  appetite. 

The  first  class  of  facts  is  only  interesting  on  account  of  the  mechan- 
ism from  which  in  such  cases  the  digestive  symptoms  arise.  Clinically 
the  gastric  symptomatology  is  usually  swallowed  up  in  the  great 
number  of  phenomena  of  which  the  patients  complain.  Generally  they 
are  themselves  aware  of  the  contingent  and  accessory  nature  of  these 
troubles.  As  they  are  the  most  common,  they  are  also  the  least  interest- 
ing of  the  functional  gastropathies. 

2.  Gastric  Obsessions  and  Phobias^ — A  neurasthenic  is  afflicted  with 
vague  dyspeptic  troubles.  He  has  no  definite  symptomatology;  neither 
vomiting,  regurgitations,  pains,  nor  heart-burn.  Sometimes  he  even  has 
no  special  dyspeptic  symptoms,  not  even  those  which  we  have  just 
noted  in  our  first  class  of  patients.  He  has  an  excellent  appetite,  he 
digests  well;  being  of  an  emotional  type  and  easily  depressed,  he  is 
liable  to  have  obsessions.  Sometimes  spontaneously,  and  because  he 
has  heard  it  said  that  analogous  conditions  to  his  could  be  the  fore- 
runner of  a  poor  state  of  digestion,  but  more  often  because  his  attention 
has  been  medically  fixed  on  his  digestive  tract,  he  wiU  become  the 
victim  of  a  true  gastric  obsession,  combined  with  food  phobias.  Pay- 
ing the  strictest  attention  to  himself,  he  will  begin  to  classify  foods. 
This  one  has  no  perceptible  effect  upon  him,  that  one  he  cannot  digest 
at  all,  while,  on  the  other  hand,  another  agrees  with  him  remarkably 
well.  Taken  by  themselves,  certain  foods  are  easily  digested,  but  eaten 
together,  they  do  not  agree  with  him  at  all.  The  patient's  whole  life 
is  regulated  by  an  incalculable  number  of  restrictions,  all  of  which 
have  to  do  with  the  digestive  functions,  and  which,  in  proportion  as  his 
affection  becomes  established,  grow  more  numerous  and  more  com- 
plicated. If  you  question  any  of  these  patients  at  the  beginning  of 
their  trouble,  you  will  be  astonished  at  the  very  slight  symptoms  of 
which  they  complain.  Further,  it  may  be  noted  that  the  majority  of 
the  difficulties  from  which  they  suffer,  and  for  which  they  hold  their 
food  responsible,  have  only  the  remotest  connection  with  the  digestive 
tract.  It  is  in  this  class  of  patients  that  you  will  find  individuals  who 
2 


18  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

do  not  eat  in  order  that  they  may  do  better  work;  in  this  class  also 
you  will  find  a  whole  category  of  people  who,  having  read  books  upon 
dietetics,  have  begun  to  put  themselves  through  a  regular  course  of 
experiments.  It  is  the  form  of  functional  gastropathy  in  which,  among 
society  people,  the  elements  of  fashion  and  snobbery  play  their  rôles. 
The  well-served  and  bountifully  provided  tables  of  our  fathers  have  been 
turned,  as  it  were,  into  veritable  dietetic  tables.  Mr.  X.  has  his 
régime,  Mrs.  Y.  has  hers.  We  must  hasten  to  add  that  often  these  régimes 
are  wholly  conventional,  and  that  they  do  not  withstand  the  appeal  of 
a  well-served  appetizing  dish,  or  that,  though  followed  most  rigorously 
at  meal-time,  they  cease  to  exist  at  the  confectioner's  or  at  a  late  supper 
at  some  social  affair.  The  matter  might  be  taken  very  lightly,  as 
worth  nothing  but  a  passing  word  of  ridicule,  if  it  were  not  that  people 
who  are  predisposed  by  obsessions,  phobias,  and  scruples  sometimes  go 
so  far  that  they  meet  disaster. 

We  have  seen  patients  of  this  kind  who,  by  reason  of  insufficient 
food,  and  extreme  malnutrition,  have  become  so  excessively  thin  and 
weak,  that  they  have  fallen  prey  to  organic  affections,  and  although 
such  cases  with  grave  physical  consequences  are  not  very  numerous,  the 
moral  and  social  effects  are,  on  the  other  hand,  very  frequent,  par- 
ticularly in  the  middle  and  poorer  classes  of  society.  While  in  the 
majority  of  cases  stomachic  phobia  is  grafted  on  to  a  more  or  less  acute 
gastric  condition,  it  is  also  often  the  case  that  it  is  the  gastric  psychosis 
which  makes  the  patient  neurasthenic,  by  reason  of  the  moral  and 
material  preoccupations  which  it  begets. 

Slowly  accumulated  savings  are  melting  away  at  the  doctor's  and 
druggist's.  The  constant  watching  of  the  state  of  his  stomach  diverts 
the  individual  from  his  daily  business.  The  inevitable  outcome  is  social 
and  business  failure,  which  finally  leads  to  a  serious  and  lasting  neuras- 
thenic state,  due  to  the  lack  of  the  essential  elements  required  to  resume 
normal  life. 

And  why  should  all  this  be?  Because  the  unfortunate  person  in 
whom  a  gastric  obsession  has  been  set  going  has  never  come  across  a 
physician  who  could  determine  the  exact  nature  of  his  trouble,  and 
put  him  on  his  guard  against  all  the  consequences  which  might  result 
from  it;  and  because,  on  the  contrary,  it  generally  happens  that  the 
physician  who  has  cared  for, him  has  not  been  sufficiently  warned  him- 
self of  the  extreme  impressionability  of  such  persons,  and  has  uncon- 
sciously done  all  that  he  could  to  set  him  definitely  upon  his  downward 
way. 

Such  patients  are  purely  nervous  or  purely  mental  cases.  The 
pathogeny  of  their  condition  is  evident,  and  scarcely  needs  discussion. 
It  only  needs  a  few  well-directed  questions  to  bring  it  out  sharply. 

Do  you  want  examples?  Here  are  a  few  taken  from  a  class  of 
patients  in  society. 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         19 

Mr.  X.,  fifty-two  years  of  age,  and  a  high  dignitary,  of  large  fortune 
and  very  well  known  in  the  Parisian  world,  has  lived  for  the  last  twenty 
years  upon  poached  eggs,  boiled  potatoes,  broiled  meats,  and  cooked 
fruits.  His  diet  has  been  limited  exclusively  to  these  four  foods.  Mr.  X. 
often  dines  in  town.  On  these  occasions  he  fasts,  because  his  rule  is 
strict  and  absolute,  and  he  will  not  allow  himself  a  single  exception. 
For  twenty  years  he  has  never  once  tried  to  evade  these  dietetic  obliga- 
tions. And  what  was  the  origin  of  all  this?  A  few  vague  dyspeptic 
troubles,  without  any  logical  cause,  and  of  no  duration,  which  happened 
to  follow  an  emotional  depression  caused  by  some  family  troubles. 
Grafted  onto  these  troubles  was  a  doctor's  prescription,  which  resulted 
in  so  fixing  the  patient's  mind  in  this  direction  that  for  twenty  years 
he  has  nursed  a  stomach,  which  otherwise  would  have  cheerfully 
tolerated  a  bottle  of  good  Burgundy  at  every  meal. 

This  case  is  simply  amusing,  for  the  patient,  by  the  way,  eats  an 
enormous  amount,  is  very  active,  and  his  morale  is  excellent. 

We  might  cite  the  case  of  a  certain  patient  who  could  eat  nothing 
except  bread;  of  another  who  could  eat  eggs  in  the  morning,  but  could 
not  touch  them  at  night.  It  would  make  an  extremely  curious  chapter, 
and  one  full  of  surprises,  if  one  were  to  note  all  the  dietetic  selections 
practised  by  such  patients.  But,  as  a  matter  of  fact,  as  long  as  the 
restrictions  in  food  are  simply  qualitative,  and  the  modifications  of 
diet  nothing  but  a  habit,  and  the  patient's  morale  remains  sound,  such 
doings  are  not  at  all  serious.  Nevertheless  they  sometimes  turn  out 
unfortunately  after  all.     The  following  case  is  an  example: 

It  concerns  a  man  thirty-six  years  of  age,  an  officer  of  infantry  in 
8  town  in  Northern  France.  He  had  been  ill  for  eleven  years.  Having 
failed  at  St.  Cyr,  he  enlisted.  He  succeeded  in  being  admitted  to  Saint 
Maixent.  There  he  worked  tremendously  hard,  was  constantly  over- 
taxed, and  left  the  school  absolutely  run  down.  He  then  found  him- 
self confronted  by  a  whole  series  of  difficulties  in  the  way  of  his  career 
which  overwhelmed  him  morally.  Becoming  thinner  and  thinner,  and 
having  lost  thirty  pounds  in  a  few  months,  he  began  to  pay  attention 
to  his  stomach. 

He  then  went  to  see  one  physician  after  another.  Some  examined 
his  gastric  chemistry,  others  put  him  upon  a  diet;  there  was  one  who 
made  him  undergo  treatment  by  static  electricity.  From  that  time  on 
he  had  a  fixed  idea;  the  unfortunate  man  took  no  notice  of  anything 
else  but  his  stomach,  and  neglected  his  calling.  Without  ever  having 
had  the  slightest  characteristic  gastric  symptom,  he  was  continually 
trying  to  find  out  what  foods  digested  easily,  and  which  did  not  digest 
so  weU.  Following  all  his  own  personal  observations,  as  well  as  the 
various  régimes  which  had  been  laid  down  for  him,  he  continually 
restricted  his  diet  more  and  more,  both  as  to  quantity  and  quality, 
until  it  was  extremely  reduced.     His  condition  becoming  graver,  he 


20     STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

gave  himself  up  to  doing  nothing.  To  the  preoccupations  of  his  career 
were  added  those  of  material  cares.  In  this  very  emaciated  condition, 
he  was  dragging  out  a  pitiful  and  apparently  hopeless  existence. 

As  a  matter  of  fact,  this  patient  is  completely  cured,  has  returned 
to  his  former  way  of  living,  and  takes  no  more  interest  whatsoever  in 
his  stomach. 

We  could  cite  thousands  of  examples  of  this  kind.  There  is  not  a 
week  but  at  the  Wednesday  consultation  at  the  Salpêtrière  at  least 
half  a  dozen  such  patients  present  themselves,  and  tell  this  stereotyped 
tale:  "I  have  grown  very  thin;  I  no  longer  eat  anything.  I  have 
been  obliged  to  give  up  my  work,  or  my  profession.  I  had  to  do  it, 
for  they  say  I  have  stomach  trouble. '^  This  procession  is  all  the  more 
lamentable  because  the  patients  have  nothing  the  matter  with  them 
except  purely  psychic  difficulties.  Their  affection  belongs  by  definition 
to  the  category  of  avoidable  diseases.  All  their  physical,  material,  and 
moral  failings  would  never  have  occurred  if  they  had  been  cared  for 
at  first  by  a  physician  who  paid  some  little  attention  to  their  mental 
hygiene  and  psychic  prophylaxis,  and  who  knew  by  what  mechanism 
this  alimentary  restriction  had  been  established  in  them.  It  is  this 
mechanism  which  we  now  wish  to  develop  a  little. 

The  Psychic  Mechanism  which  Leads  False  Gastropaths  to  Adopt 
Certain  Régimes. — In  the  great  majority  of  cases  the  patients  whom 
we  have  had  to  treat  have  not  been  gastropaths  from  the  start.  More 
often,  at  the  beginning  of  their  trouble  they  were  neurasthenic,  or 
depressed,  and  experiencing  troubles  of  a  general  nature,  among  which 
a  lack  of  appetite,  or,  to  express  it  better,  a  feeling  of  not  wanting  to 
take  the  trouble  to  eat,  occupied  an  important  plaee.  The  disturbance 
which  was  to  follow  was  in  reality  bom  at  that  moment  by  an  error 
of  interpretation.  The  patients,  either  spontaneously  or  more  often  as 
a  result  of  therapeutic  intervention,  attributed  everything  that  they  felt 
to  gastric  troubles,  when  more  often  the  whole  fault  lay  in  their 
morale,  and  the  intensity  of  their  suffering  was  measured  by  the  degree 
of  their  depression. 

Prom  this  moment  the  first  psychomotor,  or  psychosecretory  mani- 
festations appeared,  and  with  them  the  whole  well-known  series  of 
sensations  of  pressure,  heaviness,  flatulency  after  meals,  which  nearly 
all  of  these  patients  will  enumerate  as  a  regular  thing.  They  very 
naturally  try  to  remedy  these  troubles  by  changing  their  diet.  In  this 
way  they  plunge  right  into  the  downward  path  of  choosing  and  rejecting 
certain  foods. 

How,  and  according  to  what  laws,  do  such  suppressions  and  elections 
become  established?  It  is  very  certain  that  the  means  will  be  purely 
mental.  In  regard  to  the  general  lack  of  appetite  of  the  patient,  the 
process  is  more  often  apt  to  be  of  a  negative  order.  The  patient  will 
keep  upon  his  list  of  foods,  not  those  which  please  him  the  most,  but 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         21 

rather  those  which  are  least  distasteful  to  him.  The  problem,  there- 
fore, presents  itself  in  the  following  manner.  According  to  what 
mechanism  is  one  food  better  tolerated  than  another  by  this  special 
class  of  patients? 

This  mechanism,  in  order  to  be  brought  out  clearly,  ought  to  be 
studied  in  patients  of  the  poorer  class,  or  at  least  in  the  less  well 
educated  class  of  society.  With  those  who,  being  more  intelligent,  have 
their  own  ideas,  which  are  often  totally  wrong,  on  the  degree  of 
digestibility  of  any  food,  the  matter  becomes  complicated.  The  more 
or  less  preconceived  ideas  which  they  have  of  food  values,  and  of  the 
length  of  time  which  it  takes  to  digest  such  or  such  a  product,  guide 
them  in  laying  down  their  dietary.  But  even  among  these  latter,  the 
mechanism,  at  bottom,  remains  the  same  and  is  revealed  by  a  little 
careful  study. 

The  food  which  would  he  the  best  tolerated  would  he  tJiat  which 
will  necessitate  the  least  effort  to  take  and  which  hy  its  qualities  would 
awaken  to  the  least  degree  the  psychic  idea  of  eating. 

This,  on  analysis,  seems  to  us  the  principle  which  unconsciously 
serves  as  the  guiding  therapy  to  most  false  gastropaths  in  the  elabora- 
tion of  their  régime. 

This  is  why,  at  the  very  beginning,  they  eliminate  from  their  foods 
all  which  are  hard  to  chew  or  difficult  to  swallow. 

It  is  well  established  that,  among  such  patients,  a  food  may  be 
excluded  from  the  daily  diet  because  it  sticks  in  the  throat.  Such  was 
the  case  with  a  patient  whom  we  had  to  care  for,  who  had  no  constriction 
of  the  oesophagus  whatever,  but  who  could  not  eat  bread  unless  it 
had  previously  been  soaked  in  water  or  milk. 

It  was  for  similar  reasons  to  this,  and  because  it  was  difficult  and 
took  a  long  time  to  chew  them,  that  these  patients  with  gastric  phobias 
always  cut  meats  out  of  their  diet  in  the  order  which  corresponds 
precisely  to  the  degree  of  difficulty  that  they  have  in  masticating  them  : 
first,  beef  and  mutton,  then  chicken,  fish  later,  when  it  had  not  already 
been  off  their  diet  list  at  the  start,  for  one  or  other  of  the  reasons  which 
we  shall  examine  a  little  later. 

It  practically  means  that,  if  the  patient  refuses  to  make  the  effort 
which  the  taking  of  rational  nourishment  implies,  all  foods  which  by 
their  taste  or  odor  remind  him  that  he  ought  to  take  nourishment,  will 
one  after  the  other  be  crossed  off  his  food  list.  These  are  the  foods 
which  ''turn  the  patient's  stomach,"  and  take  away  the  little  appetite 
which  he  may  seem  to  have.  After  having  taken  a  mouthful  of  them, 
the  patient  believes  himself  to  be,  or  feels,  nourished.  At  least,  such  are 
the  expressions  which  we  have  almost  constantly  heard  our  patients  use. 

Still  another  factor  comes  in, — ^the  idea  of  quantity.  Here  is  a 
patient  whose  chosen  diet  was  established.  If  small  quantities  at  a 
time  of  one  of  his  chosen  foods  were  presented  to  him  he  would  take 


22  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

them,  and  would  manage  in  the  end  to  get  enough.  Try,  on  the  other 
hand,  however,  to  make  him  take  a  considerable  quantity  of  this  same 
food  at  one  time,  and  he  would  say:  ^' Never,  I  could  never  eat  all  that." 
He  would  immediately  be  frightened  at  the  effort  he  had  to  make, 
and  this  food  from  that  time  forth  would  not  agree  with  him.  If  it 
did  not  agree  with  him  once  it  would  be  sharply  and  definitely  cut  off 
from  his  daily  diet. 

That  is  to  say,  in  fact,  that  every  time  that  the  psychic  impression 
of  being  obliged  to  make  an  effort  to  take  food  occurs,  whether  by 
reason  of  the  difficulty  of  mastication,  or  swallowing,  or  whether  on 
account  of  the  taste,  or  odor,  or  quantity  of  the  food  presented,  the 
patient  will  examine  himself,  analyze  his  feelings,  and  seek  to  establish 
— and  on  this  head  he  will  always  manage  to  establish — ^some  unpleasant 
result.  This  is  the  true  foundation  of  the  mechanism  of  alimentary 
restriction  in  false  gastropaths. 

Among  those  who,  being  better  educated,  have  been  in  part  in- 
fluenced by  theoretic  ideas,  and  among  those  also  who,  under  the 
guidau'ce  of  physicians,  have  been  put  upon  various  régimes,  the  out- 
come is  the  same,  thus  verifying  the  mechanism  of  this  phenomenon 
that  we  have  just  explained. 

In  the  end  these  patients  get  to  the  point  where  they  can  take  nothing 
hut  soft  food,  semi-liquid  or  liquid,  and  only  in  the  smallest  quantities. 

As  a  matter  of  fact,  in  the  majority  of  our  false  gastropaths,  who 
had  been  suffering  for  a  sufficiently  long  time,  their  regular  food 
allowance  would  oftenest  consist  of  milk  (in  quantity  rarely  more  than 
a  quart  in  twenty-four  hours)  and  one  or  two  eggs.  Sometimes  they 
added  to  this  diet  some  patent  pre-digested  food  or  vegetables  in  a  purée. 
The  very  rare  exception  would  be  when  they  could  take  a  little  finely 
chopped  meat  fairly  floating  in  a  broth. 

We  must  hasten,  however,  to  add,  that  all  these  restrictions  are 
not  necessarily  regularly  progressive.  According  to  the  moral  con- 
dition of  the  moment  our  false  gastropaths  may  arrive  at  this  ultimate 
régime,  which  we  have  just  described,  either  very  rapidly,  or  slowly 
and  surely,  or  by  successive  starts,  separated  sometimes  by  periods 
of  great  improvement. 

This  study,  which  shows  just  how  far  these  subjects  who  have  simple 
phobias  of  the  stomach  may  go  in  the  matter  of  dietary  restriction, 
leads  us  to  the  third  class  of  patients. 

3.  Established  False  Gastropathies. — Nervous  gastropathies  with  com- 
plex symptomatology  may  be  established  at  the  outset.  More  often  these 
affections  are  only  the  end  results  of  the  forms  which  we  have  just 
described.  Here  the  patients  whom  we  are  now  considering  show 
distinct  signs  of  recognized  gastric  affections.  Vomiting  of  food,  late 
vomiting,  occurring  several  hours  after  eating,  or  even  in  the  morning 
before  breakfast;  heart-burn,  faint  feelings  of  regurgitation,  frequent 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         23 

eructations,  pains  at  the  pit  of  the  stomach,  occurring  spontaneously  or 
after  taking  food  ;  tardy  pains  with  heart-burn,  sharp  pain  on  an  empty 
stomach  soothed  by  taking  food  or  hot  drinks;  pain  to  the  touch  in  the 
region  of  the  stomach  :  all  these  are  found  variously  combined.  Here,  you 
would  say,  is  pyloric  stenosis  with  stasis;  there  you  would  say  hyper- 
chlorhydria;  here  you  would  believe  there  was  a  gastric  fermentation; 
sometimes  even  the  thought  of  an  ulcer,  or  a  cancer  in  the  early  stages 
of  its  development  will  come  to  you,  so  definite  is  the  symptomatology, 
and  so  changed  sometimes  is  the  general  condition  as  to  seem  to  imply 
the  existence  of  an  organic  affection  of  the  stomach. 

Before  entering  into  the  discussion  of  these  cases,  we  wish  to  relate 
a  certain  number  of  observations: 

Mr.  C,  forty-two  years  of  age,  an  engineer,  has  been,  for  ten  years, 
nursing  himself  for  a  gastric  affection  characterized  by  the  following 
symptoms:  heaviness;  distention  and  feeling  of  weight  after  meals; 
three  or  four  hours  later,  feelings  of  heart-bum  ;  sour  regurgitation,  and 
frequent  eructations  ;  ahnost  complete  loss  of  appetite  ;  vomitings,  rather 
frequent  and  copious,  occurring  several  hours  after  meals,  and  even 
in  the  morning  before  breakfast;  very  marked  emaciation  and  insomnia. 

The  affection  has  very  evidently  had  its  starting  point  in  alcoholic 
excesses,  and,  although  for  ten  years  the  patient  has  completely  ceased 
to  drink,  the  original  trouble  has  nevertheless  persisted.  Our  patient, 
who  is  a  foreigner,  has  been  in  all  the  world-famed  sanitaria.  He  has 
been  in  Berlin,  in  Paris,  in  Switzerland.  The  results,  obtained  by 
means  of  therapeutic  methods  based  exclusively  on  régime  and  phar- 
maceutic medication,  have  been  absolutely  nil.  He  came  to  us  in 
exactly  the  same  condition  that  he  was  in  ten  years  ago,  except,  however, 
that  his  mental  state  had  grown  progressively  worse.  He  felt  extremely 
exasperated  in  not  being  able  to  lead  the  life  that  everybody  else  led, 
and  he  found  himself  limited  in  his  activities  by  his  gastric  trouble, 
and  his  feeling  about  his  condition  had  gone  to  such  lengths  that  some- 
times he  thought  of  suicide.  Now  in  a  month's  time  this  patient  was 
put  upon  his  feet  by  psychotherapy,  and  his  gastric  troubles  have 
absolutely  disappeared. 

Madame  B.,  forty-eight  years  of  age,  a  very  nervous  woman,  living 
in  Paris,  and  having  led  a  life  of  considerable  excitement,  has  been 
cared  for  for  the  last  two  years  by  stomach  specialists.  They  told 
her  that  she  had  an  attack  of  hyposthenic  dyspepsia,  with  secondary 
fermentations.  As  a  matter  of  fact,  she  presented  all  the  classic  signs  of 
this  affection,  distentions,  pains,  regurgitations,  gas,  anorexia,  bilious- 
ness and  constipation.  She  was  put  upon  a  reduced  diet  by  one  of 
her  physicians,  and  lost  considerable  weight,  while  the  phenomena, 
sometimes  objective  and  sometimes  subjective,  only  grew  worse.  Then 
she  was  subjected  to  bismuth  treatment  of  the  stomach,  and  again  there 
was  no  result.    In  addition  she  was  ordered  to  take  absorptive  powders. 


24  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

combined  with  nux  vomica.  The  results  were  wholly  unfavorable.  She 
was  a  purely  nervous  woman  whom  the  proper  means  cured  in  three 
weeks. 

Here  are  a  certain  number  of  eases,  taken  from  our  hospital  practice  : 

The  first  is  that  of  a  woman,  fifty-seven  years  of  age,  cared  for  in 
the  Pinel  Ward,  bed  number  16,  in  the  isolation  service,  which  one  of 
us  organized  at  the  Salpe trière.  She  stayed  there  from  the  28th  of 
March  to  the  7th  of  June,  1905.     I  give  her  history  in  her  own  words. 

''Having  suffered  with  my  stomach  for  twenty-five  years,  as  the 
result  of  an  emotional  disturbance,  I  had  completely  lost  my  appetite. 
I  never  felt  the  slightest  need  of  eating,  and  I  felt  aversion  to  the  sight 
of  food,  especially  of  meat.  I  consulted  more  than  fifty  physicians. 
They  all  prescribed  a  milk  diet.  I  could  never  take  more  than  two 
quarts  of  milk  and  one  or  two  eggs  a  day,  oftener  nothing  at  all. 

"In  all  the  hospitals  where  I  went  for  consultation,  they  looked 
at  my  yellow  skin,  and  everywhere  with  the  same  thought  :  'Oh  !  nothing 
can  be  done  for  her.'  They  were  convinced  that  I  either  had  a  cancer 
or  pyloric  lesions.  Two  years  ago  they  wanted  to  operate  upon  me. 
The  physician  who  was  taking  care  of  me  in  the  last  place,  becoming 
discouraged,  sent  me  to  a  specialist,  who  kept  me  under  observation  for 
eighteen  months. 

"They  always  put  me  upon  a  milk  diet,  but  finally  I  could  take 
almost  none,  as  I  suffered  too  much  from  pains  in  the  stomach  and 
intestines.  I  continued  to  grow  thinner,  and  I  was  completely  dis- 
couraged. They  tried  lavage  of  the  stomach,  plasters,  gavage;  but 
nothing  did  me  any  good.'' 

This  auto-observation  needs  to  be  amplified  in  several  points,  and 
in  particular  as  to  the  starting  point  of  this  affection  which  brought 
the  patient  to  us. 

Twenty-five  years  ago,  she  had  a  husband,  who  has  since  died  of 
general  paresis,  who  was  brutal  to  her,  and  who  one  fine  day,  reversing- 
the  proper  order  of  things,  wanted  to  lock  her  up  in  an  asylum.  She 
was  intensely  frightened,  and  felt  her  stomach  close  as  it  were.  Since 
that  time  the  same  sensation  would  come  every  time  that  the  patient 
experienced  any  emotion.  And  emotions  were  of  daily  occurrence,  being' 
caused  by  her  son,  who  was  lacking  in  regard  for  her.  She  used  to  wait 
in  anguish  for  him  to  come  into  the  house.  But  the  moment  that  she 
saw  him  come,  she  would  experience  a  sensation  of  restriction,  and 
could  no  longer  eat.  Thus  were  developed  and  encouraged  the  evidences 
of  this  gastropathy,  whose  symptomatology  was  at  one  time  so  char- 
acteristic that  surgical  intervention  was  deemed  necessary. 

We  have  nothing  particular  to  note  concerning  the  residence  of 
the  patient  at  the  hospital.  The  first  day  she  took  three  quarts  of 
milk,  at  the  end  of  the  week  she  was  taking  five,  and  by  degrees  she 
was  put  upon  an  ordinary  diet.     Weighing  eighty-eight  pounds  when 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         25 

she  came  in,  she  weighed  one  hundred  and  fourteen  when  she  went 
out, — she  had  therefore  gained  twenty-six  pounds.  She  went  away 
completely  cured.  She  has  been  seen  several  times,  and  again  this 
spring  (1910),  and  she  has  kept  in  excellent  health  for  five  years. 

This  was  a  case  in  which  a  casual  examination,  owing  to  the  cachectic 
appearance  of  the  patient  and  the  gastric  symptomatology,  would  sug- 
gest the  diagnosis  of  a  neoplasm.  In  reality  it  was  nothing  but  a  case 
of  a  gastropathy,  the  functional  nature  of  which  appeared  when  questions 
as  to  its  etiology  were  carefully  put. 

Another  patient,  aged  thirty-six,  entered  the  Pinel  Ward,  bed 
number  11,  on  March  22,  and  went  out  completely  cured  on  June  5, 
1905,  having  gained  eighteen  pounds  in  weight.  Here  is  what  she 
wrote  us  before  leaving,  on  our  request  that  she  should  relate  her 
own  history: 

"I  am  a  natural  child.  My  mother  married,  and  had  two  children. 
I  have  always  been  treated  as  a  stranger.  As  I  was  by  nature  very 
affectionate  I  experienced  great  grief  on  this  account,  which  increased 
as  I  grew  older.  When  I  became  old  enough  to  work  they  gave  me 
no  leisure.  I  had  to  work  without  any  recreation.  Sometimes  six 
weeks  would  go  by  without  my  having  a  chance  to  go  out  of  the  house. 
I  became  anaemic,  and  had  three  hemorrhages  from  the  lungs.  After 
that  my  mother  had  a  long  illness  and  then  I  had  to  work  day  and 
night.  Then  I  had  a  mucous  fever.  In  consequence  I  became  very 
nervous,  and  could  neither  eat  nor  sleep.  I  was  always  wanting  to 
cry,  and  instead  of  being  encouraged,  I  was  repulsed.  I  led  this  sad 
existence  until  I  was  twenty-nine  years  of  age,  when  I  married.  Having 
a  good  husband  I  was  better.  At  the  end  of  the  year,  I  had  a  child. 
He  died  in  a  single  day.  My  condition  was  then  aggravated  anew.  I 
went  several  months  without  being  able  to  eat.  I  suffered  extremely 
with  my  stomach.  Three  years  ago  one  of  my  children  was  nearly  killed. 
My  condition  then  became  somewhat  serious,  so  that  I  could  not  take 
more  than  a  quart  of  milk  a  day.  I  consulted  ten  physicians,  who 
treated  me  for  gastric  dyspepsia,  and  dilatation  of  the  stomach,  but  no 
treatment  did  me  any  good.'' 

On  questioning  this  patient  on  the  stomachic  symptomatology  of 
which  she  complained  on  entering  the  service,  this  is  what  was  found: 
heart-burn,  very  sharp  pains  after  meals,  and  particularly  when  she 
had  taken  meat  ;  a  sensation  of  tension  and  distention  after  meals,  with 
very  slow  digestion;  pain  brought  on  by  pressure  in  the  region  of  the 
pit  of  the  stomach.  It  was  more  than  could  be  expected  that  physicians 
who  were  not  sufficiently  alert  should  fail  to  be  led  to  believe  in  the 
real  existence  of  a  gastropathy. 

But,  eight  days  after  her  entrance,  the  patient  took  five  quarts  of 
milk  in  twenty-four  hours.  It  was,  nevertheless,  very  difficult  to  make 
her  take  meat.    During  the  month  of  April  she  consented  to  try  it  for 


26  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

the  first  time,  then  she  refused  it  again.  At  that  time  it  was  necessary 
to  be  rather  determined  in  this  matter.  She  decided  to  try  meat  diet 
again,  and  in  ten  days  she  succeeded  in  taking  and  digesting  a  beef- 
steak every  other  day,  when  formerly  a  single  mouthful  caused  her 
intolerable  pain. 

By  the  time  she  left  the  hospital,  her  stomachic  psychism  was  com- 
pletely under  control.  **She  digested  without  knowing  it."  Moreover, 
it  seemed  that,  under  the  influence  of  her  sojourn  in  the  Salpêtrière, 
she  had  succeeded  in  curbing  her  emotional  tendencies  somewhat,  and 
had  herself  pretty  well  in  hand. 

Here  is  then  a  second  instance  where  a  stomachic  symptomatology, 
that  was  sufficiently  pronounced  to  deceive  several  physicians,  proved 
to  be  in  fact  only  a  false  gastropathy.  The  mechanism  of  the  progres- 
sive psychic  localization  showed  itself  clearly.  Of  an  emotional  tempera- 
ment, and  having  undergone  a  series  of  small  shocks  when  she  was 
overworked,  she  became  first  a  neurasthenic.  Then  little  by  little,  largely 
due  to  the  different  diagnoses  of  physicians,  her  stomach  first  came 
upon  the  scene  and  then  occupied  the  whole  stage.  She  felt  all  the 
symptoms  which  the  doctors  had  tried  to  find  in  her  case.  The  proof 
of  this  lies  in  the  very  diversity  of  the  established  diagnoses. 

A  woman  forty-eight  years  old  entered  the  Pinel  Ward  in  June, 
1905,  in  whose  case  many  physicians  would  have  made  a  diagnosis  of 
pyloric  stenosis,  or  Reichmann's  disease. 

We  shall  let  her,  also,  tell  her  own  story. 

**You  have  asked  me  some  of  the  details  which  brought  about 
the  condition  in  which  I  arrived  here.  When  I  was  very  young,  I 
was  obliged  to  work  extremely  hard,  but,  as  I  had  a  good  constitution, 
several  hours  of  rest  would  suffice  to  keep  up  my  strength. 

*' During  the  siege  of  1870,  I  underwent  a  great  many  privations, 
but  they  had  no  effect  upon  me.  It  also  seemed  to  me  that  work  and 
privations  never  hurt  me.  It  was  only  mental  worries  that  in  the 
long  run  were  able  to  break  down  my  energy  and  my  will.  I  could 
have  been  very  happy,  but  I  had  the  unfortunate  idea  of  wanting  to 
keep  my  mother  with  me  in  my  household,  and  in  spite  of  all  my 
efforts  I  never  managed  to  make  my  mother  and  my  husband  agree. 
I  only  succeeded  in  making  all  three  of  us  horribly  miserable,  and  that 
lasted  ten  years.  In  these  ten  years  of  friction  and  tears  I  became 
very  irritable  and  very  nervous. 

"In  the  month  of  September,  1896,  I  had  attacks  of  vomiting, 
with  a  feeling  of  aversion  for  all  food.  At  night  I  would  throw  up 
water  and  bile  and  in  the  daytime  I  vomited  nearly  everything  I  took. 
My  weight  went  down  to  only  ninety-six  and  a  half  pounds.  This 
state  lasted  three  years  and  a  half. 

''In  the  month  of  May,  1902,  I  lost  my  mother.  The  vomiting  and 
pain  which  I  had  experienced  came  back.    As  this  condition,  which  I 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         27 

was  helpless  to  overcome,  caused  me  great  moral  discomfort,  I  decided 
to  go  to  the  hospital.  I  first  went  to  Dr.  Barth,  at  Necker,  who  sent  me 
to  Dr.  Dejerine  at  the  Salpêtrière,  assuring  me  that  I  would  be 
cured.  '  ' 

On  the  fifth  day,  this  patient"  took  five  quarts  of  milk.  Her  weight 
increased  rapidly.  At  the  end  of  three  weeks  she  was  put  upon  regular 
diet.  She  digested  with  the  greatest  ease  all  the  food  that  was  given 
to  her.  She  no  longer  knew  that  she  had  a  stomach.  She  had  gained 
twenty-two  pounds,  when  at  the  end  of  July,  1905,  s^e  left  the  hospital. 

Here  is  the  case  of  a  young  patient,  whom  we  have  had  in  the 
Pinel  Ward  for  three  months.  Although  she  was  ver>^  stubborn  during 
the  first  weeks  about  her  treatment,  nevertheless,  she  ended  by  being 
cured.  Hers  was  a  case  of  painful  gastropathy,  simulating  those  that 
are  described  under  the  name  of  hyperchlorhydric  attacks. 

She  was  twenty-seven  years  old,  and  had  suffered  since  she  was 
twenty-one.  When  she  was  a  little  girl  she  was  not  very  strong,  and 
being  very  sensitive,  she  had  had  her  feelings  wounded  by  unfeeling 
relatives,  who  reproached  her  for  the  care  and  expense  which  her  health 
caused.  As  she  would  have  liked  to  have  earned  her  own  living,  the 
state  of  her  health  weighed  on  her  mind,  till  it  was  really  an  obsession. 
Suffering  first  from  simple  digestive  troubles,  she  soon  had  character- 
istic gastropathic  symptoms,  heaviness,  pains,  heart-burn,  vomitings,  each 
time  after  taking  food,  and  the  impossibility  of  taking  milk,  which 
*' curdled  on  her  stomach";  nothing  was  lacking.  This  patient  left  the 
Pinel  Ward,  on  the  12th  of  January,  1905.  In  September  we  had 
news  of  her.  Everything  was  going  almost  as  it  should.  From  time 
to  time  she  still  felt  attacks  of  depression,  during  which  she  suffered 
with  her  stomach,  but  she  knew  ''that  she  could,  and  that  she  ought 
to  take  the  upper  hand,"  and  she  succeeded  in  doing  so. 

Here  is  the  history  of  a  young  girl,  nineteen  years  old,  who  spent 
three  months  in  the  Pinel  Ward  in  1905.  She  complained  of  very- 
sharp  pains  in  her  stomach  which  came  on  two  or  three  hours  after- 
meals,  with  acidity,  burning  sensations,  feelings  of  tension  and  abdominal 
distention,  heaviness  and  sleepiness.  Here  again  the  epigastric  region 
was  painful  and  the  patient  would  hardly  let  herself  be  touched,  when 
they  tried  to  palpate  there. 

In  this  case  also,  therapeutic  treatment  was  the  cause,  and  the 
words — ^weighty  words  for  a  young  and  impressionable  mind — dilatation 
of  the  stomach,  hyperchlorhydric  dyspepsia  and  gastric  fermentation 
had  been  pronounced,  and  taken  at  their  full  value. 

The  mechanism  of  this  gastropathy  took  a  long  time  to  trace,  but 
at  the  end  of  several  days  we  succeeded  in  gaining  the  patient's  con- 
fidence, and  learned  from  what  it  arose.  It  was  an  attempt  upon  her 
virginity  which  had  given  rise  to  all  her  ill-health.  Entering  the 
hospital  weighing  ninety-nine  pounds,  the  patient  left  weighing  one 


28  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

hundred  and  twenty-three  pounds,  and  was  no  longer  concerned  about 
her  stomach.  We  have  had  recent  news  of  her,  and  her  health  continues 
to  be  excellent. 

Here  is  another  history  of  a  woman  forty-five  years  of  age,  the 
mother  of  a  family,  whose  life  has  been  very  hard.  She  was  reduced 
to  penury  after  having  lived  in  comfort.  For  several  years  she  had 
had  the  care  of  an  invalid  sister.  Her  husband  died  six  months  ago. 
One  of  her  sons  was  about  to  be  married  against  her  wishes. 

For  some  years  she  had  complained  that  her  digestion  seemed  slow 
and  difficult.  But,  after  the  death  of  her  husband,  it  took  on  quite 
a  different  aspect. 

Vomiting,  even  in  the  morning  on  an  empty  stomach,  cramps  that 
were  relieved  by  food,  elective  anorexia  for  meat,  waking  in  the  middle 
of  the  night  with  a  sensation  of  emptiness  in  the  stomach,  such  were 
the  sjrmptoms  of  which  she  complained.  There  were  no  acid  regurgita- 
tions, and  no  marked  eructations. 

This  patient  entered  the  Pinel  Ward  the  first  of  November,  1905, 
and  the  second  day  after  she  was  there  she  took  five  quarts  of  milk. 
By  the  15th  of  November  she  had  gained  nine  pounds. 

She  was  soon  put  upon  regular  diet,  which  agreed  with  her  per- 
fectly, and  she  left  the  Salpêtrière  cured  at  the  end  of  six  weeks.  She 
had  gained  twelve  pounds,  and  when  we  saw  her  last  she  was  in 
excellent  condition. 

Before  entering  the  Salpêtrière  she  had  seen  nine  physicians,  who 
had  treated  her  ior  a  gastric  affection,  the  name  of  which  changed  with 
every  physician  consulted.  It  seemed  in  her  case  almost  as  if  the  whole 
stomachic  psychosis  might  be  of  medical  origin.  Complaining  vaguely 
of  her  digestion,  she  had  had  her  attention  fixed  on  her  stomach  by 
medical  questions  and  examinations  which  had  preceded  the  actual  ap- 
pearance of  the  symptoms  inquired  after. 

A  case  bearing  on  this  subject  is  that  of  a  young  woman,  twenty- 
eight  years  of  age,  who,  having  formerly  been  rheumatic,  had  a  mitral 
lesion  of  the  heart,  that,  being  badly  compensated  for,  caused  her  to 
pant  when  she  made  any  effort. 

In  her  the  gastric  troubles  were  noticeable  chiefly  after  meals, 
and  especially  when  she  made  any  movement.  They  consisted  in  slight 
regurgitation,  with  frequent  eructation,  and  a  sensation  of  heaviness 
and  weight  and  distention  after  eating.  When  she  walked,  as  she 
did  from  time  to  time,  these  first  phenomena  would  grow  worse,  and 
vomiting  set  in. 

This  patient  at  the  end  of  fifteen  days  had  gained  four  pounds. 
She  no  longer  had  any  pains,  nor  did  she  vomit.  It  took  two  months 
to  accomplish  her  cure. 

What  in  her  case  was  the  mechanism  which  produced  these  gastric 
troubles?     She  had  had   a  pregnancy  which  had  ended  six  months 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         29 

before,  in  the  course  of  which  she  had  had  a  number  of  gastric 
phenomena,  and  in  particular  very  frequent  vomiting.  It  was  in  this 
way  that  her  attention  had  been  drawn  for  the  first  time  to  that  part 
of  her  body.  But  her  pregnancy  had  also  influenced  her  heart  con- 
dition, and  when  afterwards  she  wanted  to  walk,  she  would  immediately 
begin  to  suffer  from  shortness  of  breath.  She  attributed  the  whole 
thing  to  her  stomach,  and  from  that  arose  this  strange  gastropathy, 
which  was  exaggerated  when  the  patient  walked,  and  grew  less  when 
she  rested,  with  regular  variation. 

In  this  particular  case  there  certainly  was  a  somatic  lesion,  but  it 
was  of  the  heart,  and  not  of  the  stomach,  and  it  was  this  previous  psychic 
orientation  of  the  patient  which  was  the  cause  of  the  false  gastropathy. 

Here  finally  is  our  last  case  : 

Madame  M.,  forty-nine  years  of  age,  entered  the  Pinel  Ward  on 
the  4th  of  January,  1906.  She  was  suffering  from  a  gastropathy, 
which  dated  back  to  1870,  a  gastropathy  with  recurring  attacks,  which 
grew  worse  at  intervals,  but  which  did  not  become  definitely  established 
until  1890.  At  this  time  she  had  a  very  bad  influenza,  which  left  her 
much  exhausted  for  some  time.  As  she  was  indispensable  to  her  husband, 
whom  she  helped  in  his  little  business,  the  inactivity  which  she  was 
forced  to  endure  was  extremely  hard  to  bear.  While  thus  morally 
upset  and  weakened,  she  was  seized  with  very  marked  gastric  disturb- 
ances,— with  vomitings,  sometimes  with  mucus,  sometimes  with  bile,  but 
never  of  food.  She  exhibited  great  interest  in  the  advice  of  her  physician, 
and  paid  close  attention  to  the  character  of  these  vomitings,  so  much 
so  that  they  continued  until  her  entrance  to  the  hospital. 

She  went  away  on  the  17th  of  February,  completely  cured,  having 
gained  ten  pounds  in  weight.  She  was  seen  quite  recently.  The  vomit- 
ings had  never  returned,  and  everything  pointed  to  the  conclusion 
that  they  had  disappeared.  The  patient  was  convinced  of  this  as  well 
as  ourselves. 

When  we  tried  to  find  the  exact  point  of  departure  in  this  patient's 
affection,  it  was  quite  easy  to  settle  the  origin,  and  to  determine  the 
mechanism. 

It  was  during  the  privations  of  the  siege  of  Paris  that  she  felt  her 
first  gastric  disturbances.  One  can  only  too  easily  picture  the  con- 
dition of  a  little  anaemic  girl  of  fourteen  under  these  circumstances. 
She  was  taken  to  a  physician  for  a  consultation,  but  he  treated  her 
for  her  stomach,  and  with  powders  and  other  medications  which  were 
freely  dispensed  to  her,  she  plunged  headlong  into  a  functional  gas- 
tropathy. A  few  digestive  troubles  which  she  had  felt  as  a  consequence 
of  the  unusual  food  during  the  siege  was  the  origin  of  her  sickly 
condition,  but  therapy  established  her  troubles  upon  a  firm  basis,  and 
having  oriented  the  patient's  psychism  made  a  definite  thing  of  what 
from  its  nature  should  have  been  merely  transitory.    Thus  the  functional 


30  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

gastropathies  also  are  the  offspring  of  the  siege  .  .  .  and  of  the  physicians. 

These  are  a  few  facts.  We  pould  multiply  them  almost  indefinitely. 
But  they  must  be  interpreted.  To  start  with,  there  are  a  certain  number 
of  definite  ideas  which  we  have  gained  as  a  direct  result  of  our  observa- 
tions. 

The.  first  is,  that  there  exist  gastropathies,  having  all  the  clinical 
appearances  of  what  are  called  organic  gastropathies,  and  which  are 
susceptible  of  cure  without  any  kind  of  special  therapy,  by  the  general 
processes  of  treating  the  psychoneuroses. 

The  second  is,  that  in  all  these  cases  the  psychic  factors,  which 
appear  to  have  intervened,  are  the  indefinite  psychic  prolongation  of 
acute  conditions  by  the  phenomena  of  auto-  or  hetero-suggestion,  par- 
ticularly by  medical  education,   and  finally  emotional  manifestations. 

The  third  is,  that  the  symptomatology  of  our  patients  was  suffi- 
ciently acute,  and  the  objective  phenomena  sufficiently  numerous  to 
dispel  from  the  start  any  question  of  error  of  interpretation  on  the 
part  of  observers,  or  of  simulation  on  the  part  of  the  patients.  The 
problem,  therefore,  presents  itself  to  u^  in  the  following  manner:  Just 
to  what  point  is  emotion,  error  in  mental  interpretation,  medical  edu- 
cation, suggestion,  capable  of  creating  gastric  symptoms?  And,  on  the 
other  hand,  to  what  degree  is  there  any  identity  between  these  mani- 
festations, shown  to  be  of  a  neuropathic  nature,  and  the  recognized 
gastric  affections? 

First  of  all,  it  is  very  certain  that  we  may  be  reproached  for  not 
having  supported  our  observations  by  chemical  examinations  of  the 
gastric  secretions.  Why  have  we  not  made  such  examinations?  Be- 
cause, first,  we  consider  them  as  only  secondary  in  value,  from  the 
point  of  view  of  diagnosis,  and  then — we  say  it  frankly — because  we 
regard  them  as  irreconcilable  with  a  psychotherapeutic  treatment,  which 
logically  depends  upon  itself. 

What  we  have  just  said  upon  the  subject  of  examining  the  gastric 
juice,  we  might  repeat  word  for  word  apropos  of  the  radioscope,  or  of 
radiography  of  the  stomach,  a  method  which  also  has,  as  its  principal 
result,  the  further  establishment  of  the  patient  in  ways  contrary  to 
those  in  which  one  is  trying  to,  and  in  which  one  ought  to  lead  him. 

But,  although  we  ourselves  have  not  made  it  a  rule  to  examine  the 
gastric  juice,  we  might  be  permitted  to  add  that  a  very  great  number 
of  our  patients,  either  at  the  hospital  or  private  clinic,  have  given  us 
the  results  of  the  chemical  examinations  which  had  previously  been 
made  upon  them  by  the  most  competent  physicians  and  chemists;  and 
the  majority,  if  not  all,  of  these  analyses  betray  marked  alterations  of 
the  normal  chemistry.  This  argues  nothing  against  us.  What  is  of 
much  interest  in  itself,  and  shows  the  slight  value  of  this  examination 
of  the  gastric  juice,  from  the  diagnostic  point  of  view,  is  that  in  the 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         31 

majority  of  these  patients,  and  in  particular  those  in  private  practice 
— who  frequently  examine  into  the  condition  of  their  gastric  chemistry 
— the  results  were  most  variable.  Sometimes  in  fact  there  was  hyper- 
chlorhydria,  and  sometimes  hypochlorhydria,  sometimes  again  a  normal 
chemistry.  And  this  shows  us  that  even  when  there  are  considerable 
modifications  in  gastric  chemistry,  there  is  no  reason  to  state  that  one 
has  to  deal  with  an  affection  not  amenable  to  the  ordinary  treatment  of 
the  psychoneuroses. 

On  the  other  hand,  what  is  there  astonishing  in  the  fact  that  these 
various  psychic  modifications  just  enumerated  by  us,  such  as  moral 
shocks,  grief,  preoccupation — on  the  etiological  importance  of  which 
we  have  so  lengthily  insisted — ^should  be  able  to  bring  about  a  very 
considerable  number  of  gastric  manifestations  ? 

Nobody  doubts  that  an  emotion  is  capable  of  producing  gastric 
disturbances.  Vomiting  is  a  phenomenon  which  can  very  frequently  be 
created  by  emotion.  Psychic  impressions,  such  as  disgust,  inspired  by 
a  certain  food,  or  even  simply  by  the  memory  of  a  food,  are  able  to 
interrupt  digestion,  and  bring  on  nausea,  even  vomitings.  Is  not 
anorexia,  created  by  gastric  obsessions,  able  to  directly  cause  the  psycho- 
secretory  modifications  with  which  we  are  familiar?  Have  we  not  just 
seen  mental  anorexia,  a  psychic  phenomenon,  bring  about,  in  the  gastric 
functions,  such  secondary  disturbances  that  it  was  sometimes  very 
difficult  to  learn  to  take  food  again? 

Under  these  conditions,  it  seems  to  us  legitimate  to  hold  that  in 
very  many  cases  there  is  a  substitution  of  a  psychic  pathogeny  for  a 
peripheral  pathogeny,  without  denying  the  real  existence  of  motor  or 
secretory  modifications,  which,  however,  we  consider  as  being  created 
directly  by  emotional  factors,  such  as  education,  error  in  mental  in- 
terpretation, auto-  or  hetero-suggestion. 

And,  if  one  is  willing  to  admit,  on  the  other  hand,  what  is  only  too  ( 
evident,   that  all  trouble  that  is  susceptible  of  being  cured  by  per- 
suasion is  a  neuropathic  trouble,  the  demonstration   of  the  existence 
of  affections  of  the  stomach,   organic  in   appearance,   but  psychic  in 
cause,  would  seem  to  us  to  be  unquestionably  established. 

It  remains  for  us  to  ascertain  what  is  the  proportion  of  cases  in 
which  a  peripheral  pathogeny  is  imposed.  Most  certainly  we  do  not  seek 
to  deny  the  existence  of  alcoholic  or  drug  gastropathies.  We  are  quite 
convinced  that  there  are  hyperchlorhydric  dyspepsias  of  which  ulceration 
may  be  an  accompanying  factor,  and  which  have  developed  without  any 
neuropathic  cause.  There  are  gastric  troubles  in  connection  with  other 
organs,  the  liver,  peritoneum,  intestines,  kidneys,  etc.  It  is  none  the 
less  true  that,  if  we  refer  to  our  personal  statistics,  among  the  persons 
whom  we  have  treated,  and  who  complained  of  dyspeptic  troubles,  more 
than  four-fifths  were  purely  and  simply  nervous.     Nearly  all  those 


32  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

in  this  last  category  had  been,  we  ought  to  add,  considered  by  others 
as  gastropaths  properly  so-called,  and  had  been  futilely  treated  for  a 
long  time — often  for  years.  We  repeat  again — for  just  here  lies  the 
question  of  difference  and  misunderstanding — that  we  do  not  deny  the 
actual  existence  of  symptoms  verified  by  stomach  specialists;  only,  in- 
stead of  referring  them  to  some  primitive  disturbance  of  the  solar  plexus, 
or  gastric  innervation,  we  say  that  it  is  necessary  to  go  back  to 
the  generating  psychic  cause  of  all  these  observed  phenomena. 

The  evolution,  the  progress,  the  diagnostic  study  of  these 
functional  gastropathies  all  tend,  however,  to  confirm  a  certain  inter- 
pretation of  things.  Do  we  not  find  that  these  affections  are  variable, 
and  dependent  to  a  certain  extent  upon  the  mental  state  of  the  patient, 
or  his  degree  of  obsession?  Do  we  not  see  symptoms,  hitherto  non- 
existent, appearing  because  they  have  been  looked  for?  And  the 
symptomatology  presented  by  our  patients  always  keeps  pace  with  their 
education,  which  is  most  often  medical.  Sometimes  certain  of  these 
patients,  under  the  influence  of  some  violent  emotion,  or  of  a  change 
in  their  lives,  completely  forget  their  gastric  affection  from  one  day  to 
another.  What  physician  has  not  seen,  young  girls  of  a  marriageable 
age,  who  had  dyspeptic  attacks,  completely  get  rid  of  all  their  troubles 
after  a  happy  marriage?  The  organicists,  it  is  true,  attribute  every- 
thing to  the  modification  of  the  ovarian  secretion;  but,  how  common 
it  is,  when  a  child  is  seriously  ill,  or  the  household  is  not  running 
smoothly,  for  all  these  dyspeptic  troubles  which  had  been  forgotten — 
that  is  the  word — to  reappear. 

It  is,  therefore,  the  variability  of  the  affection  in  its  intensity,  in 
relation  to  moral  causes,  its  genesis  at  the  time  of  some  shock  or  crisis 
of  life,  as  well  as  its  too  rich  symptomatology,  as  a  result  of  the  most 
diverse  suggestions,  which  characterizes  for  us  the  pseudo-gastropaths, 
and  permits  us  to  make  a  diagnosis. 

4.  Dilatation  of  the  Stomach  in  Nervous  Patients. — The  history  of 
dilatation  of  the  stomach  in  neurasthenics  is  of  great  interest.  This  is 
because  dilatation  of  the  stomach,  associated  or  not  with  visceral  ptosis, 
has  been  for  some  time  considered  an  important  factor  in  neurasthenic 
conditions,  by  reason  of  the  fermentations  which  it  causes,  and  the 
auto-intoxication  of  which  it  is  the  starting-point. 

As  a  matter  of  fact,  dilatation  of  the  stomach,  with  all  its  physical 
characteristics  of  percussion  and  succussion,  appears  objectively  with 
some  degree  of  frequency  in  neuropaths.  Under  what  circumstances, 
and  by  what  means? 

It  is  met,  first  of  all,  in  cases  of  major  neurasthenia  with  exhaustion 
and  emaciation.  We  have  sometimes  seen  in  such  persons  such  ex- 
treme dilatation  of  the  stomach,  that  this  organ  descends  almost  to 
the  pubis.  This  dilatation  seems  to  us  to  be  the  result  of  the  general 
atony  of  the  patients.     There  is  no  question  in  such  cases  of  pyloric 


IVIANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         33 

stenosis  or  primitive  organic  affection  of  the  gastric  muscle.  The  proof 
of  this  is  seen  directly  from  the  fact  that  the  dilatation  of  the  stomach 
disappears  very  rapidly,  as  fast  as  the  patient's  weight  increases, 
and  that  this  occurs  in  spite  of  a  diet  which,  in  accordance  with  gen- 
eral ideas,  would  appear  absolutely  paradoxical  from  the  large  quantity 
of  liquid  which  is  represented  by  the  four  and  a  half  or  five  quarts  of 
milk  taken  each  day.  There  is,  therefore,  a  dilatation  of  the  stomach 
in  nervous  patients,  that  is  dependent  on  their  general  condition,  and 
in  which  gastric  atony  is  only  a  result  of  the  emaciation,  and  the  loss 
of  tone  of  the  muscles  of  the  organ  itself  as  well  as  in  its  relation  to 
the  body  as  a  whole. 

This  form  is  by  far  the  most  frequent,  but  it  is  not  the  only  one. 
In  fact  by  the  mechanism  already  explained,  the  nervous  patient  may 
be  an  âërophage,  where  a  purely  passive  dilatation  of  the  stomach 
is  characterized  by  extreme  variability,  and  by  all  the  objective  signs 
of  aërophagia. 

But  in  other  cases  different  mechanisms  come  into  play.  We  have 
seen  patients  suffering  from  marked  constipation,  who  presented  at  the 
same  time  a  very  considerable  dilatation  of  the  stomach.  It  is  true 
they  were  very  much  emaciated,  but  not  to  the  same  degree  as  the  major 
neurasthenics  whom  we  have  just  described.  In  such  cases  it  was 
often  sufficient  to  give  a  slight  purgative,  and  to  pay  a  little  attention 
to  educating  the  functions  of  the  bowels  to  be  regular,  and  one  would 
find  that  the  gastric  dilatation  had  suddenly  disappeared.  It  has  seemed 
to  us  that  some  people  who  are  relatively  weak  might  be  described  as 
having  a  sort  of  retro-dilatation  of  the  stomach. 

Finally  there  are  dilatations  of  the  stomach  due  to  a  complex 
mechanism,  in  which  the  atony  of  emaciation,  constipation,  and  aëro- 
phagia may,  for  various  reasons,  all  come  in  as  associated  factors. 

It  is  no  less  true  that  in  certain  subjects,  if  one  tried  to  improve 
the  symptoms  that  are  felt,  by  restriction  of  food,  as  is  only  too  often 
done,  we  would  be  apt  to  aggravate  the  local  as  well  as  the  general 
symptoms. 

As  to  the  pathogenic  rôle  played  by  these  conditions  of  stomach 
dilatation  in  the  genesis  of  the  whole  symptomatology,  it  appears  to 
us  absolutely  nil.  The  proof  of  this  lies  in  the  inconstancy  of  the 
phenomenon,  and  in  its  rapid  disappearance  under  proper  treatment. 
Many  patients  may  remain  neurasthenic  for  weeks  and  weeks  after  the 
dilatation  has  disappeared;  while,  on  the  other  hand,  unkind  as  it 
may  be  to  point  it  out,  the  fact  remains  that  many  neurasthenics  have 
never  shown  the  slightest  sign  of  such  an  affection. 

In  short,  dilatation  of  the  stomach  is  only  a  secondary  manifestation 
in  neurasthenic  conditions.     From  the  therapeutic  point  of  view,  ex- 
cept for  the  causes  which  engender  it,  it  ought  to  be  passed  over  without 
comment. 
3 


34  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

5.  Vomiting  as  a  Neuropathic  Manifestation. — Although  vomiting 
occurs  more  often,  in  the  course  of  the  psychoneuroses,  in  connection 
with  a  whole  series  of  other  troubles,  which  go  to  complete  the  symp- 
tomatology, yet  it  may  also  in  some  circumstances  constitute  the  only 
objective  symptom  presented  by  the  patients.  For  this  reason  it  de- 
serves a  special  description,  as  well  as  for  the  reason  that  the  various 
mechanisms  which  can  produce  it  are  very  interesting  and  very  sug- 
gestive. 

Vomiting  in  general  pathologic  physiology  is  a  reflex  phenomenon, 
produced  by  various  peripheral  stimuli,  of  which  the  starting-point  may 
be  found  in  the  pharynx,  the  larynx,  the  stomach,  the  peritoneum,  etc. 

In  neuropaths  one  may  distinguish,  a  priori  from  the  point  of 
view  of  pathological  physiology,  three  kinds  of  vomiting,  namely,  vomit- 
ing created  by  emotion,  and  emotional  states,  vomiting  created  by  the 
exaggeration  of  the  peripheral  sensibilities,  and  finally,  outside  of  all 
peripheral  excitation,  vomiting  in  simple  relation  with  mental  repre- 
sentations of  any  kind. 

Emotional  vomiting  is  a  fact  which  we  are  no  better  able  to  explain 
than  we  are  any  of  the  other  emotional  reactions.  It  is  a  particular  way 
that  certain  subjects  have  of  expressing  their  emotional  condition.  Their 
emotion,  as  we  might  vulgarly  say,  takes  them  in  the  stomach.  The 
vomiting  may  be  the  only  objective  emotional  reaction,  as  also  it  may 
be  accompanied  by  phenomena  of  cardiac  depression,  with  or  without 
a  tendency  to  faint,  or  vertigo,  etc.  However  it  may  be,  the  curious 
thing  about  it  is  that  those  subjects  who  have  once  reacted  to  an  emotion 
by  vomiting,  will  react  consecutively  in  the  same  manner  to  all  the 
emotions  which  may  happen  to  come  to  them. 

Mrs.  X.  is  a  lady  seventy  years  of  age,  who  for  a  certain  number 
of  years  has  complained  of  gastric  disturbances  which  consist  exclusively 
of  vomitings,  which  come  on  every  time  she  experiences  any  emotion 
whether  it  be  great  or  small.  Being  of  a  very  emotional  and  senti- 
mental nature,  she  has  not  found  in  certain  of  her  children  those 
sentiments  of  affection  which  she  would  like  to  see.  Very  often,  when 
she  comes  to  take  a  meal  at  the  house  of  one  of  them,  she  finds  herself 
chilled  and  upset  by  the  attitude  which  they  show  to  her.  That  is 
enough,  she  is  obliged  to  leave  the  table,  and  begins  vomiting. 

These  symptoms  date  back  five  or  six  years.  They  were  produced 
the  first  time  on  the  occasion  of  a  violent  emotion,  but  at  the  time 
they  did  not  make  any  impression  on  the  patient,  who,  being  very 
intelligent,  took  into  consideration  their  emotional  cause.  It  was  not 
until  much  later  that  she  paid  any  attention  to  it,  when,  although 
the  memory  of  this  great  emotion  of  her  life  had  disappeared,  she 
found  herself,  in  spite  of  everything,  reacting  in  the  same  inconstant 
manner  to  all  her  little  emotions. 

That  suggestion  played  its  part  with  this  lady,  not  only  at  the 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         35 

actual  time,  but  in  the  too  frequent  reproductions  of  her  symptoms 
afterwards,  is  not  only  possible,  but  probable;  but,  at  the  beginning, 
all  the  circumstances  of  the  psychological  condition  of  the  patient 
would  have  seemed  to  be  against  the  purely  suggestive  interpretation 
of  the  phenomena. 

Emotion,  it  would  thus  appear,  can  play  an  autonomous  pathogenic 
rôle  in  the  onset  of  vomiting,  as  well  as  in  its  persistent  recurrence. 

Vomiting  once  started,  or  at  least  made  too  easy  and  too  frequent, 
by  the  exaggeration  of  the  peripheral  sensibilities,  corresponds  to  known 
clinical  facts. 

There  is,  first  of  all,  a  whole  series  of  individuals  who  cannot  swallow 
a  powder,  or  a  pill  without  throwing  it  up.  A  little  cream  in  the  milk, 
for  some  people,  is  sufficient  to  produce  the  same  phenomenon.  Here 
it  is  a  question  of  quasi-constitutional  irritability,  for  one  sees  the 
thing  happen  even  in  little  children.  Along  the  same  line  of  ideas, 
there  are  subjects  who  react  by  vomiting  to  certain  sudden  movements, 
such  as  swinging,  see-sawing,  etc. 

We  must  add,  however,  that  often  these  subjects  encourage  them- 
selves to  become  progressively  worse,  and  become  more  and  more 
sensitive  by  a  regular  education  of  their  reflexes,  but  it  seems,  never- 
theless, in  all  such  cases  there  must  be  something  that  is  partly 
constitutional. 

The  cure  is  by  no  means  the  same  for  those  patients  who  are 
afflicted  with  neuropathic  disturbances  of  their  upper  digestive  tracts 
(dysphagias  of  all  kinds,  and  spasms  of  the  œsophagus),  and  who  have 
frequent  attacks  of  vomiting  whenever  they  take  any  food  that  is  in 
the  least  degree  solid,  or  not  sufficiently  masticated.  It  is  evident  that 
here  the  intervention  of  a  mental  representation  of  some  kind  may 
be  held  responsible  for  the  phenomena.  Nevertheless,  it  has  seemed 
to  us  as  if  certain  patients  must  really  have  an  exaggerated  reflectivity, 
which  is  the  result  of  their  attention  to  this  disturbance,  and  of  the 
secondary  education  induced  by  it,  for  they  actually  are  sometimes 
taken  with  vomiting  at  the  moment  when  they  are  least  thinking 
about  it. 

In  fact,  the  great  majority  of  neuropathic  vomitings  are  due  to 
mental  representations  which  are  produced  without  any  peripheral 
stimulation.  The  most  healthy  individual  will  often  find  that  any 
vivid  or  definite  idea  which  brings  about  a  feeling  of  disgust  for  some 
food  that  he  has  taken  is  enough  to  make  him  begin  to  vomit  or  at 
least  feel  a  sense  of  nausea. 

It  is,  in  fact,  usually  through  the  intervention  of  mental  repre- 
sentations which  are  exaggerated  and  unlikely,  that  neuropathic  vomit- 
ings occur  in  the  ease  of  neurasthenics  who  have  no  appetite  or  in 
anorexics  who  feel  the  sensation  of  disgust  at  the  sight  of  all  food. 

Under  other  circumstances,  by  keeping  in  mind  the  idea  of  the 


36  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

impossibility  of  digestion,  or  even  simply  in  an  automatic  manner, 
due  to  habit  (merycism),  some  patients  voluntarily  set  out,  more  or 
less  consciously,  to  make  themselves  vomit.  They  get  the  result  more 
or  less  easily  at  first,  but  as  vomiting  is  susceptible  to  education,  it 
is  apt  to  be  the  case  that  at  the  end  of  a  certain  time  these  vomitings 
become  very  easy,  as  easy  as  they  are  frequent. 

Disgust,  the  mental  representation  of  digestive  incapacity,  whether  or 
not  due  to  gastric  or  digestive  symptoms  of  any  kind,  or  the  establishing 
of  some  custom  at  a  certain  time  vvhich  has  fixed  the  psychism  of  the 
patient,  all  these  are  the  mechanisms  which  are  present  in  establishing 
vomiting  in  the  course  of  mental  anorexias,  false  gastropathies  of  every 
kind,  merycism,  or  rumination,  and  which  may  also  complicate  the 
pathogeny  of  vomitings  due  to  emotional  attacks  or  to  exaggeration 
of  the  peripheral  sensibility. 

To  conclude,  a  résumé  of  the  pathogenic  study  which  we  have 
just  made  might  be  set  forth  in  the  following  classification: 

I.  Emotional  vomitings. 

II.  Vomitings  caused  by  exaggeration  of  the  peripheral  sensibility. 
(a)   Constitutional,   (&)   acquired. 

III.  Vomitings  caused  by  mental  representations,  (a)  By  disgust, 
(&)  by  representation  of  inability  to  digest,  (c)  by  habit. 

We  therefore  consider  vomiting  as  a  symptom  in  a  great  number 
of  neuropathic  conditions.  It  may  in  itself  give  rise  to  secondary 
symptoms.  Sometimes,  for  instance,  vomitings  may  be  so  frequent  that 
they  prevent  all  assimilation,  outside  of  any  question  whatever  of 
insufficient  food. 

We  thus  see  how  what  may  be  called  uncontrollable  vomiting  may 
be  established.  It  is  quite  possible  that  certain  of  the  uncontrollable 
vomitings  of  pregnancy  may  be  put  in  this  class  of  neuropathic  vomit- 
ings. We  have  not  wholly  made  up  our  minds  on  this  point,  but 
there  certainly  are  cases  of  uncontrollable  vomiting  which  are  purely 
neuropathic,  particularly  in  the  case  of  hysterics.  They  cannot  naturally 
occur  without  involving  considerable  loss  of  nourishment,  which  in  itself 
is  very  serious.     They  may  also  give  rise  to  nervous  anurias. 

On  account  of  the  condition  of  syncope  which  it  can  bring  about, 
vomiting  may  become  a  factor  in  a  whole  series  of  consecutive  troubles, 
false  cardiopathies,  production  of  vertigoes,  etc.  We  shall  come  across 
all  the  phenomena  further  on,  when  we  shall  also  dwell  more  fully 
upon  certain  descriptive  or  pathogenic  points  which,  in  order  to 
avoid  repetition,  we  have  only  briefly  noticed  here. 

To  sum  up  all  that  has  gone  before,  concerning  the  presence  of 
gastric  sjmiptoms  in  the  course  of  the  psychoneuroses,  we  will  state 
that  a  certain  number  of  gastric  symptoms  are  found  among  neuras- 
thenics, and  that  whether  objective  or  subjective,  they  all  have  their 
cause,  either  in  the  emaciated  condition  of  the  patients,  or  in  their 


JVIANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         37 

more  or  less  developed  anorexial  condition,  which  brings  with  it  a 
whole  series  of  gastric  obsessions,  and  alimentary  phobias.  If  the  symp- 
toms can  be  localized  in  the  stomach,  their  true  cause  lies  in  the  psychism 
of  the  subject.     The  patients  are,  to  put  it  briefly,  false  gastropaths. 

C.  Functional  Troubles  Connected  with  Defœcation,  and  Their 
Consequences. — M.  X.  is  a  very  distinguished  ecclesiastic.  Madame  Z. 
is  a  society  woman,  the  mother  of  a  family.  The  observations  made  on 
these  two  patients  are  exactly  analogous.  Neither  the  one,  nor  the 
other,  had  ever  had  any  serious  neuropathic  symptoms.  With  the 
one,  as  with  the  other,  the  same  trivial  accident  was  the  starting-point 
of  numerous  troubles,  which  for  a  long  time  completely  upset  their 
lives. 

It  was  a  question,  purely  and  simply,  of  a  slight  ''accident,"  which 
had  soiled  their  linen,  and  necessitated  a  brusque  interruption  of  their 
occupations  to  hurry  into  the  house  and  repair  the  mishap  caused  by 
the  passing  of  a  burst  of  wind.  Ever  since,  these  two  patients  lived  in 
constant  dread  that  the  same  accident  would  happen  again,  and  place 
them  in  a  ridiculous  position.  They  did  not  dare  to  go  out  of  the 
house,  without  first  having  had  a  movement  of  the  bowels.  By  degrees, 
under  the  dominion  of  this  obsession,  or  phobia,  they  got  to  the  point 
where  their  social  activity  was  greatly  diminished,  so  much  so  as  not  to 
be  able  to  leave  their  rooms  without  terrible  apprehension.  It  is 
hardly  necessary  to  add  that  both  of  them  became  noticeably  depressed, 
although,  as  a  matter  of  fact,  the  accident  which  they  both  dreaded  so 
much  never  occurred  again. 

A  similar  case  was  that  of  a  young  woman,  who  became  neurasthenic 
after  a  period  of  great  stress  and  emotion,  which  she  spent  at  the  bed- 
side of  her  husband,  who  was  suffering  from  typhoid  fever. 

While  taking  an  elevator  to  make  a  visit,  she  had  had  an  attack  of 
diarrhœa  and  soiled  her  underclothing.  AVhen  one  of  us  saw  her  she 
had  lived  a  most  distressing  life  for  some  eighteen  months  ;  and  for  an 
accident,  w^hich  as  a  matter  of  fact  had  only  occurred  once,  she  had 
completely  given  up  making  calls. 

These  were  cases  of  a  primary  form  of  trouble  where  the  psychism 
alone  was  the  cause,  and  ser\^e  as  an  introduction  to  our  next  subject, 
for  in  the  same  way  that  we  have  described  the  phobias  of  the  stomach, 
we  shall,  apropos  of  such  patients,  take  up  the  study  of  the  diarrhœa 
phobias. 

There  are  also  constipation  phobias.  These  occur  most  often  in 
individuals  who,  on  account  of  some  organic  trouble,  have  been  advised 
that  they  must  never  allow  themselves  to  become  constipated.  Such 
are  patients  with  haemorrhoids,  arteriosclerosis,  people  who  have  been 
threatened  with  cerebral  haemorrhage,  and  who,  when  left  to  take  care 
of  themselves,  sometimes  exaggerate,  in  the  most  fantastic  way,  the 
medical  advice  which  has  been  given  to  them.     We  have  known  one 


38  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

patient  of  this  kind  whose  whole  existence  centred  around  that  function 
of  his  daily  economy.  He  spent  about  four  hours  every  day  in  the 
toilet.  He  was  not  constipated  in  the  slightest  degree,  but  he  was 
always  fearful  lest  he  might  not  have  completely  emptied  his  intestine, 
hence  his  exaggeratedly  prolonged  sittings.  It  can  readily  be  under- 
stood that  this  very  special  trend  of  his  life  could  not  help  but  lead 
to  a  series  of  disorders.  The  patient  was,  of  course,  hampered  in  his 
social  life  as  well  as  in  his  business,  which  he  necessarily  neglected, 
and  finally  sank  into  a  serious  neurasthenic  condition. 

It  may  be  noted  that  before  this  time  he  had  not  shown  the  slightest 
sign  of  hypochondriac  preoccupation. 

Our  first  class  of  patients  then  is  made  up  of  those  who  suffer  from 
neurasthenic  manifestations  of  diarrhœa  or  constipation.  But,  along 
with  this  first  group,  there  exist  active  diarrhœas  of  psychopathic  origin. 

Nervous  Diarrhœas, — One  knows  that  among  the  many  phenomena, 
for  which  the  emotions  may  be  responsible,  diarrhœa  is  by  no  means  the 
least  frequent.  There  are  classical  examples  of  men  w^ho  have  been 
obliged  to  give  up  political  life,  as  the  excitement  which  they  felt 
whenever  Jthey  addressed  crowds  took  this  very  special  form.  The 
diarrhœa  of  armies  is  an  emotional  manifestation  equally  well  known. 
"We  have  often  seen  emotional  people  in  whom  frequent  or  continued 
emotions  would  always  cause  the  same  trouble.  In  such  cases  there 
would  be  a  primary  form  of  nervous  or  emotional  diarrhœa,  which 
would  be  severe  in  proportion  to  the  intensity  of  the  emotion,  then 
the  phobia  of  the  diarrhœa  itself  would  also  play  a  pathogenic  rôle, 
and  prove  as  important  a  factor  as  the  emotion. 

Here  is  an  example:  A  young  woman,  twenty-eight  years  of  age, 
and  the  mother  of  three  children,  was  treated  for  four  years  for  an 
intestinal  disturbance.  She  was  put  upon  all  sorts  of  regimens,  and 
particularly  on  an  exclusive  farinaceous  diet.  They  claimed  that  in 
that  way  they  could  stop  a  persistent  diarrhœa.  The  only  result  was 
to  make  her  lose  thirty-one  pounds.  No  physician  ever  concerned 
himself  with  her  mental  conditions.  Now  what  was  the  real  trouble? 
She  was  the  daughter  of  a  man  of  prominence,  occupying  an  important 
post  in  a  foreign  country.  One  day  when  she  was  driving  with  him 
in  an  open  carriage,  they  were  fired  upon,  and  she  was  exposed  to 
the  shots  which  were  intended  for  her  father.  She  threw  herself  upon 
him  to  protect  him.  Fortunately,  neither  she  nor  her  father  was 
hurt,  but  she  was  taken  at  that  moment  with  an  attack  of  emotional 
diarrhœa,  the  memory  of  which  became  a  regular  obsession.  She  found 
herself  the  victim  of  a  perpetual  diarrhœa,  which,  however,  was  not  so 
persistent  but  that  it  would  stop  when  her  attention  was  called  to  other 
things,  which,  however,  happened  very  rarely  to  her.  The  case  of  this 
patient  was  diagnosed  as  a  pseudomembranous  enterocolitis,  and  every 
day  she  examined  her  stools  to  see  if  there  were  any  false  membranes. 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         39 

She  was  very  much  upset  over  her  condition,  and  became  profoundly 
neurasthenic. 

When  treated  therapeutically,  in  isolation,  this  patient  saw  her 
intestinal  troubles  disappear  in  a  few  days.  Starting  at  the  first  with 
ordinary  diet,  in  three  months  she  regained  her  lost  weight,  and  was 
able  to  return  to  a  perfectly  normal  life. 

Outside  of  any  kind  of  emotion,  diarrhoea  may  also  be  produced 
in  nervous  people  by  a  very  different  mechanism.  The  need  of  going 
to  the  toilet  is,  in  fact,  nothing  more  than  a  mental  interpretation  of 
a  sensation  localized  in  the  region  of  the  rectum  and  anus.  It  is  a 
phenomenon  which  we  believe  is  very  susceptible  to  education. 

Mr.  X.,  a  merchant,  forty-nine  years  of  age,  had  two  years  ago  a 
serious  attack  of  gastro-intestinal  poisoning  which  caused  profuse  diar- 
rhœa,  obliging  him  to  go  to  the  toilet  as  many  as  sixteen  or  eighteen 
times  a  day.  The  attack  was  so  depressing  to  him  that  since  that 
time  the  patient's  attention  seems  to  have  remained  fixed,  as  it  were, 
on  his  lower  bowel,  and  when  we  saw  him  he  was  still  going  to  the 
toilet  six  times  a  day  at  least.  The  diarrhoea  remained,  and  his  stools 
were  quite  unformed,  and  all  the  dietetic  treatment  to  which  he  had 
been  subjected  was  without  effect.  Large  doses  of  bismuth  and  opium 
alone  were  able  to  give  him  temporary  relief.  But  this  patient  was 
cured  rapidly  by  the  simple  prescription  of  making  himself  voluntarily 
increase  the  interval  between  his  stools.  In  order  to  avoid  any  of  the 
effects  of  obsession,  we  advised  him  to  stay  at  home,  and  to  lie  down 
during  the  hours  when  he  was  obliged  to  go  to  the  toilet,  and  to  try 
and  occupy  his  mind  by  reading  or  conversation.  In  this  way  he  man- 
aged to  go  to  the  toilet  no  more  than  four  times,  then  three  times,  then 
twice  a  day.  His  stools  became  formed,  and  the  cure  which  resulted  has 
continued  for  the  last  six  months  without  any  other  incident. 

How  are  we  to  interpret  such  a  case?  Has  it  anything  to  do 
with  an  organic  affection? 

The  very  mechanism  of  the  cure  renders  such  an  hypothesis  unlikely. 
It  seems  to  us  that  here  was  a  patient  who  had,  so  to  speak,  been 
constantly  educating  himself  from  everyone  who  had  attended  him, 
ever  since  the  first  acute  attack,  which  had  been  brought  on  by  some 
sort  of  a  *' psychic  impression."  On  the  other  hand,  it  is  certain  that 
the  fact  of  going  frequently  to  the  bath-room,  by  reason  of  the  efforts 
made  at  such  a  time,  and  the  intestinal  contractions  which  they  provoke, 
would  be  likely  to  hasten  the  passage  of  the  intestinal  contents,  and  to 
prevent  the  large  intestine  from  thoroughly  emptying  itself.  Thus  a 
permanent  diarrhoea  might  be  established  without  any  organic  reason 
for  its  existence.  This  is  the  way  by  which  what  we  might  call  diarrhoeas 
due  to  education  become  established. 

Neuropathic  Constipation.  —  Nearly  all  the  nervous  constipations 
are  due  to  a  mechanism  analogous  to  that  which  we  have  just  attempted 


40  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

to  explain.  They  are  constipations  due  to  education.  They  may 
develop  under  very  different  circumstances.  Sometimes  they  occur  in 
individuals  who,  until  that  time,  had  had  a  very  good  digestion,  but 
who  have  had  an  attack  of  some  anal  affection,  such  as  haemorrhoids 
or  fissures.  As  defecation  is  extremely  painful  to  them,  they  volun- 
tarily try  as  far  as  possible  to  put  it  off.  They  thus  finally  get  to  the 
point  of  inhibiting,  so  to  speak,  the  sensation  of  needing  to  go  to  the 
toilet,  and  even  after  the  haemorrhoidal  attack  has  disappeared,  or  the 
fissure  is  cured,  they  remain,  and  will  remain  constipated,  until  by 
inverse  education  they  teach  their  functions  to  resume  their  regularity. 

Other  individuals,  and  this  is  the  usual  cause  of  constipation  among 
women,  forget,  for  some  reason  or  other,  to  go  to  the  toilet,  jor  else 
they  will  not  make  the  proper  normal  effort  to  attain  a  favorable  result. 
They  thus  get  to  the  point  where  their  digestive  tract  is  completely 
upset,  and  we  have  seen  some  cases,  particularly  among  women,  who, 
without  suffering  any  apparent  inconvenience,  were  apt  to  go  from  one 
to  two  weeks  without  having  a  movement. 

Other  persons  educate  themselves  in  a  different  way,  and  form  a 
habit  of  having  a  movement  by  artificial  means  only,  such  as  enemata, 
or  inserting  suppositories  into  the  rectum,  etc.  In  these  cases  artificial 
defaecation  is  often  practised  without  the  slightest  preliminary  attempt 
to  have  a  normal  passage. 

Certain  individuals  reach  the  point  of  no  longer  experiencing  the 
slightest  need  of  defaecation.  It  is  an  absent  idea.  We  once  saw  a 
patient  of  this  kind  who,  from  the  time  that  he  was  three  or  four 
years  of  age,  when  his  mother,  in  accordance  with  a  medical  prescrip- 
tion, had  given  him  enemas,  had  been  completely  ignorant  of  what  it 
meant  to  go  spontaneously  to  the  toilet.  He  had  never  even  tried  it.  When 
we  saw  him,  he  was  fifty-two  years  of  age,  and  had  taken — we  amused 
ourselves  by  making  a  computation — about  fifteen  thousand  enemas. 

Finally  there  exists  a  whole  class  of  individuals  whose  constipation 
is  due  to  persuasion,  and  in  fact,  in  the  case  of  nearly  all  the  patients 
whom  we  have  just  seen,  their  constipation  was  due  to  their  laziness. 
These  latter,  being  convinced  that  they  were  afflicted  with  a  stubborn 
constipation,  would  go,  it  is  true,  to  the  toilet,  but  being  wholly  per- 
suaded that  it  was  no  use  they  would  occupy  the  time  by  reading  the 
paper  or  a  magazine. 

There  are  others  in  whom  a  cramp  occurs  almost  immediately  when 
they  call  up  the  idea  of  constipation.  How  many  times  have  we 
heard  patients  tell  us  that  when  they  went  to  the  toilet,  although  it 
seemed  to  them  at  the  time  that  the  need  was  urgent,  yet  the  moment 
they  got  there  their  **  inspiration  '  '  failed  them.  They  had  an  impression 
of  a  cramp,  which  at  some  other  time  had  actually  occurred,  but — and 
this  is  a  matter  of  by  no  means  small  importance — under  a  psychic 
influence.    If  ten.  minutes  or  a  quarter  of  an  hour  later  these  patients 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         41 

would  return  to  the  bath-room,  when  their  attention  was  distracted  by 
something  else,  the  normal  effort  would  be  attended  with  success.  But, 
though  there  is  little  danger  that  any  more  serious  phobic  manifesta- 
tions would  become  established,  or  that  the  patient  would  have  obsessions, 
yet  a  serious  and  obstinate  neuropathic  constipation  is  apt  to  set  in. 

It  goes  without  saying  that  a  constipation  due  to  education  may 
become,  after  a  certain  time,  a  real  constipation,  having  as  its  starting- 
point  nervous  symptoms  of  a  different  nature,  which  we  shall  take  up 
further  on. 

Along  with  these  constipations  of  education,  there  exists,  in  many 
neurasthenic  patients  who  are  extremely  emaciated,  a  form  of  con- 
stipation due  to  intestinal  atony,  which  is  the  result  of  the  general  low 
tone  of  the  patient's  body.  It  arises  through  a  mechanism  analogous 
to  that  which  we  have  seen  creating  a  certain  form  of  gastric  dilatation 
in  neurasthenics.  Here  the  psychism  does  not  act  directly,  but  the 
fact  remains  that  the  general  weakness  of  the  organism,  of  which  the 
gastro-intestinal  atony  is  but  a  symptom,  bears  a  direct  relation  to 
morbid  disturbances  of  a  neuropathic  nature.  It  is  none  the  less  true 
that  to  treat  these  patients  as  if  their  whole  trouble  were  centred 
around  their  constipation  would  be  quite  irrational,  and  fraught  with 
many  dangers. 

Neuropathic  Constipation  and  Diarrhœa;  Their  Immediate  and 
Ultimate  Consequences. — The  neuropathic  origin  of  a  diarrhoea,  and 
more  particularly  of  constipation,  does  not  render  these  troubles  any 
less  liable  to  bring  about  a  whole  series  of  symptoms  which  are  apt 
to  follow  in  the  course  of  a  constipation  or  a  diarrhœa  of  organic  cause. 
If  we  consider,  in  addition,  that  nervous  patients  are  very  apt  to 
voluntarily  use  every  kind  of  artificial  means,  such  as  enemata,  pur- 
gatives, etc.,  for  their  constipation,  because  they,  more  easily  than 
others,  are  apt  to  be  obsessed  on  the  subject  of  their  constipation, 
and  are  always  looking  for  some  means  of  overcoming  it;  we  are  able  to 
conceive  what  a  large  number  of  secondary  disturbances  might  be 
added  to  these  neuropathic  phenomena.  Intestinal  cramps,  profuse 
mucus  secretions  of  the  large  intestine,  or  intestinal  catarrh,  if  one 
so  prefers  to  call  it,  may  be  the  direct  results  of  a  purely  neuropathic 
constipation. 

As  for  the  diarrhœa  of  neuropaths,  it  too  is  apt  to  have  less  effect 
upon  the  local  condition  than  upon  the  general  state  of  health,  for  as 
it  hurries  the  partially  digested  food  along  too  quickly,  not  enough  can 
be  absorbed,  and  even  on  a  sufficiently  hearty  diet,  there  may  be  emacia- 
tion which  is  sufficiently  pronounced  to  be  noticed  by  the  patient  as 
well  as  the  physician. 

We  shall  not  dwell  upon  this  point,  but,  according  to  our  opinion, 
this  is  the  mechanism  in  part,  at  least,  of  the  origin  of  many  of  the 
intestinal  disturbances  which  are  found  among  neuropaths.  These  are 
the  troubles  that  we  now  have  to  consider. 


42  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

D.  Intestinal  Manifestations  of  Neuropaths. — Here  again,  as  in 
our  preceding  studies,  we  shall  have  two  classes  of  patients  to  study. 
On  the  one  hand  we  have  the  phobies,  who  are  obsessed  about  their 
intestines.  On  the  other  hand,  those  who  present  intestinal  symptoms 
of  a  purely  neuropathic  nature,  or  which  are  connected  with  some 
nervous  trouble  localized  elsewhere. 

As  far  as  the  first  class  of  these  patients  is  concerned  we  must  state 
at  once — for  this  is  a  question  which  we  shall  take  up  elsewhere — 
that  they  are  not  hypochondriacs.  The  principal  characteristic  of 
hypochondriacal  manifestations  lies  in  their  diffusion,  and  in  their 
variability.  Here  we  have  individuals  who  are  systematized,  and  whose 
intestines  have  become  the  source  of  obsessional  preoccupations.  As 
for  the  mechanisms  which  have  brought  about  the  intestinal  localiza- 
tion, they  are  numerous.  Sometimes  it  is  an  attack  of  colic  which  the 
patient  has  never  been  able  to  forget,  sometimes  it  is  something  which 
he  has  read,  or  conversations  which  have  turned  his  mind  upon  his 
intestines.  Is  it  not  a  peculiar  thing  to  see  to  how  large  a  degree  in- 
testinal manifestations  have  developed  during  the  last  twenty  years? 
We  know,  only  too  well,  that  a  large  number  of  the  cases  that  w© 
hear  of  are  cases  of  purely  neuropathic  symptoms.  Innumerable 
medicines  and  an  infinite  variety  of  diets  have  been  laid  down  for  the 
treatment  of  intestinal  affections,  and  people  who  have  never  had  the 
slightest  local  trouble  of  this  kind,  as  well  as  those  who  have  some 
trifling  complaint,  *'try"  the  medicine,  or  the  much  lauded  diet  under 
the  vain  pretext  that  ''at  least  it  can  do  them  no  harm."  But  alas! 
by  fixing  the  patients'  minds  upon  their  physical  organs,  it  does  ''do 
them  harm,"  and  one  sees  patients  going  from  one  step  to  another, 
palpating  their  abdomens,  examining  the  nature  of  their  stools,  and 
finally  ending  by  really  feeling  positive  symptoms  in  the  locality  of 
an  intestine  that  only  wants  to  be  allowed  to  perform  its  functions. 
These  are  the  false  enteritides,  the  psychics  of  the  intestine.  Their 
number  is  legion. 

There  are  also  false  appendicites.  These  are  patients  who  have  had 
some  intestinal  pain  in  the  right  groin.  Knowing  that  this  is  the 
way  in  which  appendicitis  often  appears  they  go  in  search  of  a  physician. 
He  naturally  finds  nothing  the  matter,  and  not  taking  the  patients* 
mental  condition  sufficiently  into  account,  he  advises  them  to  keep  a 
watch  upon  their  intestines,  and  not  to  neglect  consulting  a  physician 
the  moment  a  pain  of  the  same  kind  appears  again.  "Your  life,"  he 
tells  the  patients,  "may  depend  upon  it."  We  have  seen  individuals 
of  this  kind  living  for  years  in  the  expectation  of  an  attack  of  appendi- 
citis, which  never  came,  and  which  never  had  any  reason  to  come. 
While  waiting  for  it,  their  lives  have  been  spoiled.  Matters  have  some- 
times gone  even  to  the  point  of  an  operation  for  an  appendicitis  which 
did  not  exist. 

The  second  category  of  cases  is  formed  of  patipnts  presenting  some 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         43 

real  trouble  in  the  locality  of  the  intestine,  but  trouble  which  seems 
to  us  to  have  every  reason  to  be  considered  as  being  of  a  neuropathie 
nature. 

At  this  point  we  might  write  the  whole  history  of  membranous 
enterocolitis.  Here  is  an  affection  which  thirty  years  ago  was  almost 
unknown,  or  at  least,  was  so  little  known  that  one  could  easily  count 
the  cases.  Now,  in  these  later  years  it  has  become  so  widespread  that 
in  many  watering  places,  as  well  as  in  a  considerable  number  of 
sanitaria,  they  treat  this  trouble  almost  exclusively. ,  Such  rapid  growth 
is,  to  say  the  least,  singular.  Moreover,  the  patients  afflicted  with  this 
disease  are,  for  the  majority,  neuropaths,  characterized  as  such  even 
by  those  specialists  who  are  determined  to  refer  the  symptoms  to  an 
organic  origin.  There  are  no  physicians  who  do  not  recognize  that 
mucomembranous  enterocolitis  is  almost  certain  to  develop  on  a  neuro- 
pathic soil. 

Characterized  essentially  by  glairy  and  mucus  stools,  sometimes 
accompanied  by  false  membranes,  by  alternative  attacks  of  diarrhœa 
and  constipation,  by  painful  sensations  in  the  region  of  the  large  in- 
testine, just  how  can  one  tell  whether  or  not  the  symptoms  which 
constitute  such  a  diarrhœa  are  likely  to  be  nervous  in  their  origin? 

So  far  as  the  mucus  hypersecretion  of  the  intestine  is  concerned, 
it  may  be  due  to  different  factors.  The  intestinal  secretion  may  be  a 
true  phenomenon  of  defence  against  constipation,  this  being  very  fre- 
quently created,  as  we  have  seen,  in  neuropathic  soil.  Moreover,  the 
various  means  employed,  by  the  patients,  to  get  relief  are  not  without  a 
possible  irritating  action  on  the  intestinal  mucous  membrane.  Finally, 
we  may  add,  that  the  glairy  secretions  and  false  membranes  are  extremely 
frequent  in  people  who  have  never  had  any  trouble  with  their  intestines. 
In  women,  particularly  at  the  time  of  their  courses,  it  is  a  very  common 
phenomenon,  and  one  which  has  no  significance,  unless  the  attention 
of  the  subject  has  become  fixed  upon  it. 

But  in  what  degree,  on  the  other  hand,  may  the  nervous  system  be 
susceptible  of  directly  engendering  difficulties  in  the  region  of  the 
intestine?  We  have  already  seen  that  emotion  creates  diarrhœa.  It 
would  be  trite  to  state  that  constipation  frequently  occurs  in  the 
psychoses,  properly  so-called,  and  especially  in  melancholia.  We  be- 
lieve that  the  fixing  of  the  patient's  attention  on  any  part  of  his  body 
whatsoever  is  apt  to  produce  some  disturbance  in  that  region,  whether 
an  error  in  mental  interpretation  may  be  considered  as  a  cause  of 
functional  disturbances,  or  whether  one  considers  the  emotion  with 
which  the  patient  has  been  preoccupied  as  the  starting-point.  At  all 
events,  there  is  no  reason  why  the  psychic  secretory  manifestations  which 
have  been  physiologically  demonstrated  in  connection  with  the  stomach 
should  not  also  exist  in  the  intestinal  region. 

The  whole  make-up  of  the  painful  disturbances  which  enter  into  the 
symptomatology  of  mucomembranous   enterocolitis   are   too  subjective 


44  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

in  their  nature  for  the  nervous  system  not  to  be  liable  to  play  an 
important  part.  On  the  other  hand,  we  cannot  believe  that  an  over-lively 
imagination  may  of  itself  be  the  cause  of  such  troubles;  and  as  far 
as  the  painful  symptoms  of  which  the  patients  complain  are  concerned, 
we  are  of  the  opinion  that  they  really  feel  them.  According  to  our 
ideas,  the  fact  is  that  there  may  be  developed  an  exaggeration  of  the 
visceral  sensibility,  which  has  been  in  some  way  educated  by  the 
attention  of  the  patient  being  constantly  brought  to  bear  upon  that 
special  part  of  the  body.  It  must  not  be  forgotten  that  through  appre- 
hension and  fear,  impressions  may  be  felt  as  very  painful,  which  under 
other  circumstances  would  pass  by  completely  unperceived.  We  have 
seen  patients  in  whom  painful  symptoms  of  an  enteric  nature  would 
suddenly  disappear  under  the  influence  of  psychotherapy.  This  was 
probably  because  the  normal  functioning  of  the  intestine  had  been 
somewhat  painful  to  them.  As  to  the  phenomenon  of  cramps  which 
often  accompany  the  manifestation  of  a  mucomembranous  enteroco- 
litis, and  which  may  constitute  the  painful  element,  they  may  be  ex- 
plained in  very  different  ways.  Constipation — ^this  is  a  self-evident  fact 
— brings  about  spasm  of  the  large  intestine.  It  is  in  this  case  a  form 
of  mechanical  defence.  But,  on  the  other  hand,  the  condition  of  spasm 
is  the  condition  of  all  the  organs,  and  all  the  painful  muscles,  and 
whether  the  pain  be  of  peripheral  origin,  or  of  central  origin,  or  purely 
psychic  in  its  essence,  the  spasm  cannot  be  other  than  a  common  result. 

However  it  may  be — and  we  shall  find  all  these  theoretic  questions 
taken  up  later  on — we  have  seen  a  great  many  patients  attacked  by 
symptoms  described,  not  only  by  us,  as  mucomembranous  enterocolitis, 
who  were  rapidly  cured  by  the  ordinary  methods  of  treatment  of  the 
psychoneuroses. 

A  few  years  ago,  one  of  us  had  occasion  to  see  a  young  woman 
whose  husband  was  in  one  of  the  liberal  professions,  and  who  for  the 
last  ten  years  had  been  treated  for  symptoms  of  enterocolitis.  Naturally 
she  had  been  put  upon  very  reduced  diet,  of  which  the  first  result  had 
been  the  loss  of  thirty-five  pounds  of  her  weight.  Her  enterocolitis 
3vas  really  of  emotional  origin,  but  she  had  also  nursed  it  along  and 
aggravated  it  extremely  by  unwise  therapeutic  measures. 

After  three  months  of  treatment  this  woman  regained  her  normal 
weight  and  went  back  to  her  regular  life  apparently  cured.  But,  as 
a  matter  of  fact,  the  cure  was  not  realized,  because,  as  it  was  inferred 
by  the  reticence  of  the  patient,  her  pathological  convictions  had  not 
completely  disappeared.  As  a  matter  of  fact  this  patient,  when  seen 
a  year  later,  had  had  a  complete  relapse,  and  was  suffering  more  than 
ever.  We  then  got  her  complete  confession.  Her  physician  who  had 
always  treated  her  was  ill-advised  enough  to  tell  her  that  nothing  would 
be  done  for  her  intestines.  *'He  cannot  treat  you  for  your  entero- 
colitis,^' he  said  to  her,  *'for  he  does  not  believe  in  it.''     The  con- 


MANIFESTATIONS  OF  THE  DIGESTIVE  SYSTEM.         45 

vietion  that  this  woman  felt,  that  her  own  ideas  were  being  opposed 
merely  by  another  purely  theoretic  set  of  ideas,  was  what  had  kept  her 
from  giving  up  her  belief  in  the  reality  of  her  affection.  Once  having 
confessed,  she  rapidly  grew  well,  and  this  time  definitely. 

Here  is  a  case  that  is  very  interesting,  because  the  psychotherapy 
that  banished  the  symptom  came  about  spontaneously.  It  was  the 
case  of  a  woman,  forty  years  of  age,  who  had  been  separated  from  her 
husband  for  some  years,  and  who  came  to  the  Pinel  Ward  during  the 
service  of  one  of  us,  at  the  Salpêtrière,  to  be  treated  for  functional 
manifestations  of  the  bladder.  The  examination  of  our  patient  revealed 
this  truly  pertinent  fact — ^that  the  vesical  pain  dated  back  eleven  months, 
but  that  for  two  years  before  that  the  patient  had  had  characteristic 
symptoms  of  enterocolitis,  constipation,  glairj^  and  false  membranes, 
sharp  pains  in  the  iliac  fossa,  and  fœcal  matter  in  the  form  of  little 
balls.  The  diagnosis  of  enterocolitis  had  been  made,  moreover,  by 
several  physicians.  We  ought  to  add  that  this  patient,  who  was  in  a 
serious  nervous  condition,  having  had  a  great  many  material  and  moral 
cares  to  engross  her,  did  not  derive  any  benefit  from  the  various  treat- 
ments that  were  prescribed  for  her  at  that  time.  But  suddenly  on 
experiencing  real  suffering,  the  whole  symptomatology  of  enterocolitis 
had  disappeared  from  the  moment  that  the  patient's  attention  was 
localized  upon  her  bladder. 

Another  example  of  the  same  kind  is  furnished  us  by  a  patient  who 
had  suffered  for  three  years  from  enterocolitis.  This  patient  went  to 
consult  a  physician  who  attributed  her  series  of  intestinal  symptoms 
to  her  gastric  condition.  In  a  few  weeks  she  had  developed  a  false 
gastropathy,  but  her  enterocolitis  had  disappeared. 

These  are  nervous  metastases,  and  one  can  apply  the  old  proverb 
to  them, — ''One  nail  drives  out  another."  There  exist  numerous  ex- 
amples of  such  cases.  We  shall  have  occasion  to  mention  others.  They 
serve  better  than  any  theory  to  confirm  the  purely  neuropathic  nature 
of  symptoms  which  need  only  distraction,  in  the  etymological  sense  of 
the  word,  to  make  them  disappear. 

We  have  now  analytically  set  forth  all  of  the  neuropathic  mani- 
festations which  may  affect  the  digestive  tract.  In  general  these  mani- 
festations appear  under  the  form  of  phobias,  or  obsessions,  localized  in 
the  viscera,  which  may  be  complicated  by  psychomotor  or  psycho- 
secretory  phenomena,  as  well  as  by  secondary  symptoms  resulting  in 
some  way  from  the  vicious  habits  formed  in  those  parts  of  the  body 
which  we  have  just  studied. 

We  have  described  separately  each  of  the  manifestations  which  we 
have  come  across  in  our  practice,  but  it  is  very  evident  that  morbid 
associations  may  be  created  leading  to  neuropathic  syndromes,  resulting 
from  the  simultaneous  appearance  in  the  same  subject  by  diffusion,  as 
it  were,  of  several  of  the  phenomena  considered. 


CHAPTER  II. 

FUNCTIONAL   MANIFESTATIONS  IN   THE   URINARY  ORGANS. 

By  reason  of  their  frequency  these  manifestations  are  no  less  im- 
portant than  the  digestive  or  genital  disturbances.  But,  as  they  are  so 
closely  allied  to  the  latter,  we  find  it  better  to  place  their  study  before 
those  of  the  last  mentioned  localizations. 

We  shall  study  successively — 

A.  Floating  kidney  in  co7inection  with  the  psychoneuroses. 

B.  Modifications  of  the  urinary  secretions. 

C.  Difficulties  in  micturition. 

A.  Floating  Kidney  in  Connection  with  the  Psychoneuroses. — 

Floating  kidney  in  all  its  variations,  is  found  very  frequently  in  neuras- 
thenics. We  naturally  do  not  think  of  pretending  that  this  phenomenon 
constitutes  essentially  a  neuropathic  symptom.  But  we  believe  that  in 
the  majority  of  nervous  people,  if  not  in  all,  it  is  brought  about  by  the 
simple  mechanism  of  losing  flesh,  which  causes  the  fatty  capsule  of  the 
kidney  to  disappear,  and  becomes  the  factor  of  its  abnormal  mobility.  A 
floating  kidney  in  neurasthenics  is,  therefore,  only  a  secondary  mani- 
festation, and  to  attempt  to  use  its  more  or  less  frequent  occurrence,  to 
establish  a  pathogenic  theory  of  neurasthenia,  seems  to  us  dangerous 
at  least.  Of  course  we  do  not  wish  to  be  understood  as  speaking  of  a 
floating  kidney  which  has  really  become  displaced,  which  is  a  mani- 
festation independent  of  all  previous  or  consecutive  neuropathic 
phenomena,  when  we  say  that  the  floating  kidney  of  neurasthenics  does 
not  need  treatment.  When  patients  get  back  to  their  original  weight, 
they  do  not  complain  of  it  objectively.  Subjectively,  however,  they 
continue  to  complain  of  it,  for  fear  that  having  spoken  of  it  may  put 
them  in  a  false  position  mentally.  In  fact,  we  have  seen,  in  a  great 
number  of  patients,  false  floating  kidneys  following  a  true  floating  kidney, 
which  persisted  subjectively  for  a  long  time  after  the  phenomenon  itself 
had  disappeared.  In  this  way  it  creates  renal  or  lumbar  pains  which 
are  sometimes  the  starting-point  of  errors  in  diagnosis.  These  patients 
are  thought  to  have  appendicitis  or  so-called  stones,  especially  when,  as 
it  often  happens,  the  symptomatology  is  complicated  by  urinary 
phenomena.  The  floating  kidney  in  fact,  whether  persisting  or  cured, 
may  be  the  starting-point  of  numerous  neuropathic  manifestations  by 
diffusion,  and,  above  all,  when  ill-advised  therapeutic  treatment  has 
intervened. 

From  this  point  of  view  in  particular,  the  various  kinds  of  girdles 
and  corsets  or  bandaging,  which  are  definitely  indicated  in  cases  of 
true  floating  kidney,  cannot  help  but  constitute  a  real  danger  to  the 
46 


MANIFESTATIONS  IN  THE  UKINARY  ORGANS.  47 

neuropath,  by  constantly  calling  his  attention  to  it,  and  thus  creating 
obsessions  concerning  it. 

B.  Modifications  of  the  Urinary  Secretion. — We  shall  only  study 
under  this  title  the  quantitative  modification  of  the  urine  secreted.  It 
is  true  that  this  quantitative  modification  can  be  more  or  less  asso- 
ciated with  disturbances  of  micturition,  which  we  shall  glance  at  in  the 
following  paragraph.  It  is  none  the  less  true  that  the  quantity  of 
urine  secreted,  which  is  a  renal  phenomenon  without  any  immediate 
bearing  on  vesical  or  urethral  symptoms,  may  be  modified  by  purely 
neuropathic  influences. 

First  of  all,  we  shall  describe  nervous  polyuria.  This  manifests 
itself  under  many  different  conditions.  Sometimes  it  is  a  question  of  a 
purely  transient  phenomenon,  consisting  of  the  emission  of  large  quan- 
tities of  clear  urine,  which  might  be  described  as  nervous  urine.  This 
is  a  trivial  phenomenon,  without  any  ill  consequences  or  significance, 
which  may  occur  after  any  stirring  emotion.  The  only  reason  for 
noticing  it  is  because,  although  its  intrinsic  importance  is  slight,  it  may 
nevertheless,  under  some  circumstances,  become  the  starting-point  of 
fixed  ideas  and  secondary  phenomena.  In  the  majority  of  cases  which 
interest  us, — ^that  is  to  say,  in  those  in  which  the  polyuria  is  persistent, — 
it  is  a  question  of  an  habitual  mechanism,  or  of  the  education,  so  to 
speak,  of  the  organism.    It  gets  to  be  polyuria,  by  polydipsia. 

Mrs.  B.,  fifty-nine  years  of  age,  has  suffered  from  a  polyuria  for 
five  years.  She  passes  at  least  from  six  to  seven  quarts  of  urine  every 
day.  Her  urine  is  clear.  The  analysis  shows  no  pathological  element, 
and,  if  one  did  not  take  the  quantity  of  liquid  into  account,  one  would 
find  in  their  usual  proportions  all  the  mineral  and  organic  elements  of 
normal  urine.  In  spite  of  the  quantity  that  she  drinks,  the  arterial 
tension  is  very  close  to  the  normal,  and  does  not  pass  17  on  Potain's 
sphygmomanometer.  With  the  exception  of  the  polyuria  there  is  no 
objective  disturbance.  Subjectively,  the  patient  complains  of  a  whole 
series  of  troubles, — dryness  of  the  throat,  difficulty  in  salivation,  etc., 
which  occur  the  moment  that  she  goes  for  any  length  of  time  without 
drinking  something. 

What  has  happened  in  this  particular  case?  The  history  of  the 
patient  explains  the  mechanism  of  the  phenomenon  very  clearly.  Six 
years  ago  she  nursed,  both  night  and  day,  a  son  who  was  afflicted  with 
pulmonary  tuberculosis.  Being  very  emotional,  each  time  that  her  child 
had  an  attack  of  suffocation,  she  herself  felt  contractions  in  her  throat, 
and  would  drink  abundantly  to  relieve  herself.  She  thus  got  into  the 
habit  of  taking  a  large  quantity  of  liquid  every  day,  and  more  par- 
ticularly at  night.  Her  son  died  and  she  was  overcome  with  grief.  She 
did  not  sleep  at  night,  and,  haunted  by  the  memories  of  his  death,  was 
overcome  by  the  same  emotional  phenomena  which  had  been  produced 
by  his  sufferings. 


48  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

The  habit  of  drinking  a  large  quantity  was  in  this  way  kept  up. 
Since  then  the  emotional  symptoms  had  disappeared,  but  the  polydipsia 
and  polyuria  persisted.  We  must  add  that  apart  from  her  emotional 
disturbance  the  patient  has  never  shown  the  slightest  neuropathic 
trouble.  She  was  of  slightly  weak  mentality,  but  did  not  in  the  slightest 
degree  show  the  mental  make-up  of  an  hysteric.  She  had  made  great 
efforts  for  some  months  to  lessen  the  quantity  of  liquid  that  she  drank, 
she  tried  to  cheat  her  thirst  by  the  usual  methods,  but  could  not 
succeed.  It  was  necessary  to  proceed  very  slowly  with  her,  by  im- 
perceptible reductions,  in  order  to  obtain  any  perceivable  improvement. 

In  other  cases  it  is  a  question  of  subjects  who  in  the  course  of  con- 
valescence from  some  acute  illness,  typhoid  fever  for  example,  had  been 
accustomed  to  drink  liquids  in  great  quantities,  and  who  had  continued 
for  weeks,  and  even  months,  to  keep  up  the  same  kind  of  liquid  food, 
less  from  any  organic  need  of  it  than  from  the  establishing  of  a  habit 
which  made  them  feel  the  need  at  regular  and  specified  hours  of  drink- 
ing large  quantities  of  some  liquid.  This  last  class  of  patients  are  cured 
tf  very  quickly.  It  is  often  only  necessary  to  make  them  understand  the 
I   nature  of  their  polyuria  for  them  to  be  relieved  of  it  in  a  few  days. 

In  other  cases,  again,  there  are  patients  who,  for  some  reason  or 
other,  have  been  put  upon  a  milk  diet  of  four  or  five  or  six  quarts 
of  milk  a  day,  and  who,  when  their  normal  régime  was  prescribed  again, 
continued,  if  they  were  not  carefully  watched,  to  drink  in  excessive 
quantities  for  some  months.  We  have  seen  some  in  whom  the 
phenomenon  lasted  for  years. 

Here  is  still  another  mechanism.  It  is  the  keeping  up  of  the 
emotional  polyuria  to  which  we  have  just  made  allusion.  It  is  curious 
that  it  should  be  so,  but  it  very  frequently  happens  that  the  same 
individuals  nearly  always  externalize  their  emotionalism  in  the  same 
manner.  Then  there  is  also  such  a  thing  as  emotional  polyuria  due  to 
the  repetition  of  extrinsic  emotions,  as  also  the  poljoiria  itself  may  be- 
come, in  an  impressionable  patient,  the  starting-point  of  preoccupations 
and  emotional  phenomena  which  encourage  it  to  continue. 

In  short,  in  all  these  cases  we  must  take  into  account  two  mechanisms, 

I  — ^the  emotional  mechanism,  coming  directly  by  the  intervention  of  a 

polydipsia,  and  the  mechanism  of  education;  and  we  must  never  lose 

sight  of  this  fact, — ^viz.,  the  direct  action  which  emotional  phenomena 

have  upon  the  renal  secretions. 

These  are  the  true  nervous  polyurias,  which  must  not  be  confused 
with  pollakiuria  of  the  same  nature,  which  we  shall  study  later.  It 
goes  without  saying  that  they  are  more  apt  to  be  met  in  patients  who 
are  hetero-  or  auto-suggestible, — who,  for  example,  easily  persuade  them- 
selves of  the  necessity  of  drinking  large  quantities,  or  who  are  easily 
impressed  and  obsessed  by  an  accidental  polyuria.  It  is  none  the  less 
true  that  the  question  of  simulation,  whether  conscious  or  semi-con- 
scious, does  not  enter  into  the  question.    In  these  troubles  the  will  is 


MANIFESTATIONS  IN  THE  URINARY  ORGANS.  49 

not  brought  into  play.  This  does  not  mean  that  there  may  not  exist 
simulated  polydipsias  and  polyurias.  But  they  have  nothing  to  do 
with  the  true  nervous  polyurias. 

This  last  mechanism  of  simulation,  possibly  combined  with  suggestion, 
we  admit  most  readily  in  what  we  have  called  major  hysterical  polyuria. 
Here  the  quantity  of  liquid  that  may  be  drunk  and  urine  emitted  passes 
all  limits  of  imagination.  Patients  of  this  kind  have  been  known  to 
pass  from  fifteen  to  twenty  and  even  thirty  quarts  of  urine  in  twenty- 
four  hours.  That  a  certain  number  of  these  patients  are  up  to  tricks 
and  resort  to  fraud  to  fill  the  urinals  is  a  fact  not  to  be  doubted,  and 
agrees  perfectly  with  the  mentality  of  the  patients  who  are  subject  to 
such  an  affection.  They  are,  as  a  matter  of  fact,  usually  degenerate 
men,  alcoholics,  hospital  rounders,  and  wilful  simulators.  It  is  none 
the  less  true  that  very  often  the  mechanism  of  education  from  an 
antecedent  polydipsia  may  be  brought  into  play,  and  it  is  a  fact  that  a 
polyuria  often  sets  in  after  long  and  frequent  alcoholic  bouts.  But 
in  these  latter  cases  it  is  rather  a  question  of  a  true  dipsomania,  a  mental 
condition  which  is  outside  the  bounds  of  our  studies.  For  in  these  in- 
tensive polyurias  the  action  of  emotion  as  well  as  of  traumatism  have 
been  called  into  play.  We,  therefore,  feel  that  these  are  doubtful  con- 
ditions that  we  would  hesitate  to  consider  as  true  functional  manifesta- 
tions,— ^that  is  to  say,  according  to  our  conception,  as  phenomena  where 
the  conscious  will  of  the  patient  does  not  come  into  play,  and  which 
are  to  be  distinguished,  on  the  other  hand,  from  mental  manifestations 
due  to  pure  psychoses.  As  a  matter  of  fact,  these  patients  are  ex- 
tremely rare  at  the  neurological  clinic  of  the  Salpêtrière,  and  we  would 
be  rather  inclined  to  believe  that  simulation  plays  an  important  part 
because  they  are  apt  to  avoid  the  clinics  for  special  nervous  diseases, 
where,  according  to  their  opinion,  one  does  not  pay  sufficient  attention 
to  their  malady,  and  are  more  inclined  to  frequent  the  clinics  in  general 
medicine. 

But  quite  the  opposite  phenomenon  is  to  be  observed  in  ischuria, 
or  the  anuria  of  nervous  patients,  in  which  the  quantity  of  urine  secreted 
is  abnormally  reduced  almost  to  nothing.  As  a  rule,  scanty  urine  is 
closely  allied  to  the  small  amount  of  liquid  consumed.  This  may  occur 
as  a  consequence  of  mental  anorexia,  where,  as  we  have  seen,  liquids  and 
foods  are  only  taken  in  infinitesimal  quantities.  It  often  arises  from 
an  elective  anorexia  for  beverages,  from  true  nervous  sitiophobias.  How 
do  these  latter  occur?  Very  often  the  sitiophobia  is  of  medical  origin. 
A  patient  with  a  dilated  stomach,  or  afflicted  with  obesity,  has  received 
the  advice  of  a  physician  to  drink  as  little  as  possible.  Persecuted  by 
the  idea  of  the  dilatation,  or  obsessed  by  the  obesity,  and  desirous  of 
being  rapidly  cured,  such  patients  cut  down  the  amount  that  they  drink 
to  unbelievably  small  quantities.  They  finally  develop  a  fear  of  drink- 
ing, and  push  this  fear  so  far  that  they  will  refuse  foods  which  are 
rich  in  water,  such  as  vegetables,  fruits,  etc.  We  have  seen,  in  illus- 
4 


50  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

tration  of  this,  a  cachectic  young  girl,  a  false  gastropath  with  dilatation, 
who  managed  to  get  into  this  state  in  one  month's  time  and  is  still  in 
it,  where  she  absolutely  suppressed  every  kind  of  drink,  and  got  to 
the  point  where  even  the  idea  of  drinking  caused  a  real  sense  of  anguish 
analogous  to  the  condition  of  anguish  which  is  felt  by  our  polyurias  at 
the  idea  of  not  being  able  to  drink.  Under  these  conditions  such  patients 
get  to  the  point  where  they  pass  the  most  insignificant  quantities  of 
urine, — from  one  hundred  to  one  hundred  and  fifty  grams  at  most, 
during  twenty-four  hours,  of  thick  urine,  which  is  extremely  turbid  in 
certain  obese  cases.  Such  a  disturbance  may  go  on  for  a  long  time, 
while  the  health  remains  almost  normal. 

Such  cases  are  what  one  might  call  ischuria  by  adipsia,  which  repre- 
sents a  primary  category. 

To  what  extent,  on  the  other  hand,  may  emotion  or  suggestion  be 
susceptible  of  decreasing  or  suppressing  the  renal  secretion  ? 

Two  forms  of  anuria,  or  hysterical  ischuria,  have  been  described. 
One  is  simple  anuria,  characterized  by  the  simple  suppression  or  diminu- 
tion of  the  urinary  flow;  the  other  is  hysterical  anuria,  with  uncon- 
trollable vomitings,  where  there  is  established  a  sort  of  balance  between 
the  amount  of  the  vomiting  and  the  quantity  of  urine  passed.  Others 
do  not  agree  about  this  last  form.  Some  consider  that  the  vomiting 
forms  a  sort  of  supplementary  flow;  others  think  that  it  is  a  question 
of  conditions  of  gastric  intolerance,  and  that  the  suppression  of  urine 
really  depends  upon  the  non-alimentation  of  the  subject.  We  ourselves 
are  more  inclined  to  throw  our  opinion  on  the  side  of  this  latter 
interpretation. 

We  have  seen  elsewhere  how  many  gastric  manifestations  of  neuro- 
pathic origin  there  may  be,  and  how  the  gastric  reflectivity  was  in- 
fluenced by  the  phenomenon  of  emotion  and  hetero-suggestion.  In  fact, 
in  the  case  of  anuria  with  uncontrollable  vomiting  which  we  have  out- 
lined, the  patient  was  perfectly  convinced  that  her  stomach  could  not 
tolerate  anything.  As  for  her  anuria,  she  considered  it  a  purely  secon- 
dary phenomenon.  She  had  not  even  paid  any  attention  to  it.  It  is 
very  certain  that,  under  the  influence  of  her  conviction  of  gastric  in- 
tolerance, she  ate  only  with  feelings  of  repulsion  on  account  of  the 
nauseas  and  vomitings  arising  from  a  purely  psychic  cause.  One  can 
conceive  how  in  these  conditions  psychotherapy  can  easily  get  control 
of  these  states. 

So  far  as  pure  and  simple  urinary  suppression  is  concerned,  it  is 
a  phenomenon  which  has  often  been  observed  in  hystericals,  following 
an  attack  or  an  emotion.  This  is  usually  a  purely  transitory  anuria, 
lasting  from  twenty-four  to  thirty-six  hours.  As  to  the  prolongation 
of  the  phenomenon  for  a  very  considerable  time,  although  we  know 
to-day  that  the  retention  of  calculi  in  the  ureter  is  compatible  with 
life  for  a  rather  long  space  of  time,  it  leaves  us  rather  sceptical.  And 
here  we  would  be  very  much  disposed  to  admit  the  intervention  of 


MANIFESTATIONS  IN  THE  URINARY  ORGANS.  51 

simulation.  As  a  matter  of  fact,  these  patients  can  scarcely  be  said  to 
flock  to  the  special  clinics  for  nervous  diseases,  and,  as  far  as  we  our- 
selves are  concerned,  we  have  never  observed  a  single  example  of  urinary 
suppression  in  hysteria. 

To  sum  up  these  functional  manifestations  which  lead  to  the  re- 
duction of  the  urine,  we  see  that  total  or  elective  anorexia  and  gastric 
intolerance  play  a  part.  If  sometimes  an  emotion  may  come  in  in  a 
direct  manner,  it  does  not  seem  to  us  any  less  true  that  the  majority  of 
these  modifications  of  the  urinary  secretion  are  due  to  modifications  of 
absorption.  And  this  conforms  pretty  generally  to  the  idea  with  which 
we  started  at  the  beginning  of  our  study, — ^namely,  that  the  functional 
manifestations  properly  so  caUed,  outside  of  the  phenomenon  of  strong 
emotion,  require  the  intervention  of  mental  representations,  and  that 
the  functions  which,  like  the  secretion  of  urine,  have  no  mental  repre- 
sentation must  intrinsically  be  but  slightly  affected. 

C.  Disturbances  of  Micturition. — Disturbances  of  micturition, 
whether  isolated  or  associated  with  genital  troubles,  are  extremely  fre- 
quent in  nervous  people,  and  particularly  among  neurasthenics.  They 
occur  almost  exclusively  in  men. 

In  order  better  to  understand  them,  it  seems  to  us  necessary  to  offer 
a  few  preliminary  remarks  upon  the  physiological  mechanism  of  the 
excretion  of  the  urine. 

The  bladder,  owing  to  its  muscular  development,  forms  an  elastic 
reservoir  which  dilates  in  proportion  to  the  amount  of  urine  secreted  by 
the  kidney  and  brought  into  it  by  the  ureters.  This  wholly  passive  dila- 
tation is  made  possible,  on  the  one  hand,  by  the  fluted  beak  arrangement 
of  the  urethral  orifice,  which  permits  the  urine  to  flow  in,  but  prevents 
it  from  flowing  out,  and,  on  the  other  hand,  by  the  presence  of  the  smooth 
sphincter.  The  sphincter,  in  its  condition  of  elastic,  and  perhaps  tonic, 
contraction  (whether  reflex  or  not),  is  still  further  reinforced  in  men 
by  the  prostate,  which  presses  elastically  upon  the  urethra. 

When  the  bladder  has  attained  the  limit  of  its  normal  elasticity,  its 
sensory  nerves  are  stimulated,  and  transmit,  to  the  vesicospinal  centres 
of  the  spinal  cord,  an  excitation  which  is  reflected  on  the  motor  nerves, 
and  thus  the  muscular  walls  of  the  bladder  are  caused  to  contract.  Some 
drops  of  urine  then  involuntarily  overflow  the  smooth  sphincter,  from 
the  neck  of  the  bladder,  and  come  in  contact  with  the  mucous  membrane 
of  the  prostatic  region  of  the  urethra.  They  there  provoke  the  peculiar 
sensation  known  as  the  desire  to  urinate.  If  one  resists  the  desire,  the 
striated  and  voluntary  sphincter  of  the  prostatic  and  membranous  regions 
contract  and  hold  back  the  urine  in  the  bladder  for  a  time.  Then  the 
desire  reappears,  and  finally  becomes  irresistible.  At  last  the  voluntary 
sphincter  relaxes,  and  the  contractions  produced  by  the  bladder  and 
helped  by  those  of  the  muscles  of  the  abdomen  little  by  little  force  the 
urine,  which  is  ejected  in  the  form  of  a  continuous  stream  at  first,  but 


52  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

which  becomes  intermittent,  and  goes  in  little  spurts  at  the  end.  These 
spurts  are  due  to  the  contraction  of  the  bulbocavernous  muscle,  which 
expels  from  the  urethra  those  last  drops  of  liquid  on  which  the  con- 
tractions of  the  bladder  and  abdominal  pressure  could  no  longer  act. 

In  short,  in  micturition  the  intervention  of  superior  centres  is  mani- 
fested several  times, — ^namely,  in  the  sensation  of  wanting  to  urinate, 
in  the  interpretation  of  the  sensation,  in  the  voluntary  contractions  of 
the  striated  sphincter  to  hold  back  and  the  contraction  of  the  abdom- 
inal wall  and  the  bulbocavernous  muscle  to  hasten  and  terminate  mic- 
turition. The  vesical  contraction  itself,  by  the  intermediary  of  spinal 
centres  of  arrest,  may  in  a  certain  measure  be  inhibited  by  the  will. 

In  these  conditions  of  normal  micturition,  which  presuppose  the  in- 
tervention of  the  psychism,  it  is  quite  easy  to  understand  that  it  may 
often  be  disturbed  in  neuropaths  by  the  psychic  fixation  of  the  patient 
upon  his  bladder  and  his  genito-urinary  organs.  The  first  problem  which 
presents  itself  to  us  has  to  do  with  the  mechanism  itself  which  causes 
this  fixation. 

It  often  happens,  and  we  shall  find  these  facts  a  little  further  along, 
in  connection  with  the  study  of  functional  genital  manifestations,  that 
the  urinary  symptoms  are  only  secondary,  and  are  derived  from 
localized  genital  troubles.  But  often  also  there  has  been  fixation  on  the 
bladder  and  urethra  from  the  start.  It  sometimes  occurs  in  patients 
who,  having  had  urethritis,  are  haunted  by  the  fear  of  stricture.  They 
consult  a  physician,  he  passes  a  sound,  but  he  may  assure  them  in  vain 
that  their  urethra  is  normal;  the  nail  has  been  driven  in,  and  the 
patient's  preoccupation  grows  more  intense  every  day.  Under  other 
circumstances  the  starting-point  is  quite  different.  A  patient,  for  ex- 
ample, has  been  known  to  develop  the  whole  symptomatology  of  a  false 
urinaire,  because,  having  one  day  gone  too  long  without  relieving  him- 
self, he  had  a  slight  attack  of  false  incontinence  or,  on  the  contrary, 
considerable  difficulty  in  voiding  the  urine. 

The  rôle  of  emotion,  on  the  other  hand,  may  play  an  important 
part.  Everybody  has  experienced  pollakiuria,  a  frequent  and  repeated 
micturition,  amounting  often  to  a  mere  trifle,  and  causing  one  to  hurry 
for  nothing  at  all,  which  one  experiences  when  under  the  stress  of  an 
emotion.  Such  a  condition  offers,  either  by  the  continuity  of  the 
emotion  or  by  secondary  psychic  fixation,  a  mechanism  which  could 
produce  functional  urinary  symptoms. 

Moreover,  there  are  physiological  phenomena  which  will  aggravate 
the  matter.  There  is  a  slight  prostatic  congestion  which  occurs  in  the 
morning,  from  an  overfull  bladder,  which  by  lessening  the  force  and 
size  of  the  jet  can  become  the  starting-point  of  an  erroneous 
interpretation. 

Under  other  circumstances  again  it  is  a  question  of  real  urinary 
modifications.     The  passing  of  a  little  sand  or  urinary  phosphates,  or, 


MANIFESTATIONS  IN  THE  URINARY  ORGANS.  53 

on  the  contrary,  the  exceeding  clearness  of  the  urine,  will  preoccupy 
the  patient  and  make  him  fix  his  mind  on  his  urinary  functions. 

Sometimes  patients  will  be  subjects  suffering  from  some  heart  trouble 
who  know  that  the  quantity  of  urine  bears  some  relation  to  their  cardiac 
contractions  and  who  will  thus  have  their  attention  drawn  to  the  organs 
of  urinary  secretion.  It  is  not  only  the  accidental  polyurias  by  taking 
of  diuretic  liquids  or  follo\\âng  a  migraine,  but  also  comparative  anuria 
which  may  be  created  by  energetic  purgation  or  very  abundant  perspira- 
tion, all  of  which,  though  trifling  causes  in  themselves,  may  produce 
great  effects  in  this  domain  of  functional  manifestations. 

However  it  may  be,  we  shall  take  up  successively  retention  of  urine, 
incontinence,  poUakiuria,  pains  in  the  urinary  passages,  and  all  the 
modifications  (properly  so  called)  of  micturition. 

True  urinary  retention — ^that  is  to  say,  the  impossibility  of  volun- 
tary micturition — is  a  rare  symptom.  It  has,  however,  been  noted  in 
hystericals,  who  can  go  twenty-four  or  even  thirty-six  hours  without 
urinating,  following  an  emotion,  a  traumatism,  or  an  hysterical  crisis. 

What,  however,  is  extremely  frequent,  is  the  inhibition  in  various 
degrees  which  certain  patients  have  of  the  sensation  of  the  desire  to 
urinate.  Sometimes  it  is  connected  with  phenomena  which  are  wholly 
foreign  to  the  urinary  tracts,  and  one  sees  people  who  are  under  the 
influence  of  an  obsessive  idea  or  a  preoccupation  or  lasting  emotion 
forgetting  to  urinate  for  a  greater  or  less  length  of  time.  Sometimes 
these  are  prostatics  or  have  phobias  concerning  their  urinary  tracts, 
and  voluntarily  hold  back  their  micturition  as  long  as  possible,  and  who 
manage  in  this  way  to  educate  themselves  to  go  without  voiding  urine 
more  than  once  or  twice  during  the  day,  less  from  need  than  by  reason- 
ing. Among  these  patients  there  is  created,  under  the  direct  mental 
influence,  a  spasm  of  the  striated  sphincter  of  the  urethra,  and  this 
sphincter  may  become  subjectively  and  objectively  painful. 

Urinary  incontinence  may  be  met  with  under  very  different  con- 
ditions. First  of  all,  one  must  remember  that  there  is  a  false  incon- 
tinence which  may  be  observed  in  hysterical  patients  who  are  retaining 
their  urine  and  who  urinate  because  their  bladder  overflows.  This, 
however,  is  a  phenomenon  rarely  observed.  True  partial  or  relative 
incontinence  is  of  very  frequent  occurrence  in  women,  and  we  know 
that  certain  women  when  the  bladder  is  full  are  unable  to  laugh  heartily 
or  make  the  slightest  violent  effort  without  voiding  at  least  a  few  drops 
of  urine.  The  phenomenon  in  itself  is  nothing,  but  may  become  serious 
by  the  obsessive  preoccupation  which  it  may  cause.  We  have  seen  one 
lady  of  this  kind  shut  herself  up  completely  for  fear  of  causing  an 
accident,  which,  however,  had  never  occurred  with  her  outside  the 
bounds  of  physiological  possibilities.  We  knew  another  woman  who 
was  so  preoccupied  with  the  subject  that  she  got  to  the  point  where 
she  had  involuntary  micturition  so  abundantly  that  she  wet  her  clothing 


54  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

and  undergarments,  although  the  micturitions  were  created  solely  by  the 
mental  representations  which  she  had. 

In  certain  neurasthenic  men  one  sees  phenomena  of  the  same  kind. 
They  are,  however,  very  rare,  and  are  generally  allied  to  pollakiuria. 

The  nocturnal  incontinence  of  children  or  of  youths  is  a  functional 
trouble  which  does  not  have  anything  to  do  with  the  manifestation  of 
psychic  origin  which  we  are  studying  here.  As  to  true  and  absolute 
incontinence,  we  for  our  part  have  never  met  any  examples  among 
neuropaths. 

Frequency  of  micturition  is  a  common  phenomenon  among  neuras- 
thenics. It  is  directly  caused  by  urinary  obsession.  The  patient,  think- 
ing too  frequently  or  continuously  upon  his  urinary  tracts,  invites  by 
his  mental  representation  contraction  of  the  bladder,  and  experiences 
as  a  consequence  the  desire  to  urinate.  We  see,  moreover,  analogous 
mechanisms  in  normal  life,  for  a  desire  to  urinate  is  essentially  con- 
tagious, and  individuals  who  are  not  in  the  least  neuropathic  will 
rarely  allow  their  companions  to  go  alone.  It  is  for  this  reason  that  in 
our  urinary  neurasthenics  everything  that  is  likely  to  call  their  attention 
to  their  urinary  tracts  becomes  the  starting-point  of  a  desire  to  urinate. 
It  cannot  be  other  than  the  fear  of  not  being  able  to  satisfy  their 
pollakiuria  which  is  the  starting-point  of  their  imperious  desire,  which 
sometimes  amounts  to  real  agony. 

One  of  us  treated  in  his  service  at  the  Salpêtrière  a  woman,  twenty- 
eight  years  of  age,  who  became  pollaMuric  as  a  result  of  emotions, 
and  who  for  eighteen  months  did  not  go  out  of  her  apartment,  for, 
whenever  she  did  go  out,  she  was  haunted  by  the  idea  that  she  was 
going  to  urinate  and  would  be  obliged  to  relieve  herself  no  matter 
where.  In  her  own  home,  however,  knowing  that  the  toilets  were  in 
close  proximity,  she  did  not  pass  urine  any  more  often  than  would  a 
normal  subject.  She  was  cured  after  six  weeks  of  isolation  and  psycho- 
therapy. 

These  patients  are  profoundly  unhappy,  for  all  social  life  is  im- 
possible to  them.  They  go  from  one  physician  to  another  and  from 
one  drug  to  another.  They  abstain  from  drinking  or,  on  the  con- 
trary, they  take  great  quantities  of  liquid,  and  create  additional  troubles. 
Psychotherapy  is  the  only  thing  that  is  able  to  cure  them. 

An  unfortunate  laborer,  a  mushroom  raiser,  came  to  us  in  an  in- 
tensely neurasthenic  condition.  He  was  a  false  urinadre.  He  experienced 
pains  in  the  perineal  region  and  was  attacked  with  very  marked  fre- 
quency of  micturition.  The  origin  of  all  this  was  nothing  more  than 
a  slight  eczema  of  the  penis  which  had  appeared  four  years  before, 
but  which  had  been  the  starting-point  of  his  psychic  fixation  through 
medical  encouragement.  As  the  patient  was  not  very  young,  the  doctors 
thought  it  would  be  a  good  idea  to  make  him  undergo  a  course  of 
massage  of  the  prostate,  the  latter  being  by  some  pronounced  large 
and  hypertrophic  and  by  others  small  and  sclerotic!    It  must  be  noted, 


MANIFESTATIONS  IN  THE  URINARY  ORGANS.  55 

and  this  is  important  from  a  diagnostic  point  of  view,  that  this  pol- 
lakiuria  was  purely  diurnal  and  that  it  disappeared  entirely  during  his 
sleep. 

Sometimes  his  frequency  of  micturition  was  accompanied  by  partial 
incontinence,  due  to  the  too  imperious  demands  upon  the  patient,  which 
he  believed  did  not  give  him  time  to  relieve  himself  in  a  rational  manner. 
But  this  is  a  very  rare  case.  More  often  the  patients  who  at  this  time 
feel  themselves  wet  are  so  not  through  urine,  but  on  account  of  an  ex- 
aggerated secretion  of  the  bulbourethral  glands,,  whose  presence  is 
recognized  by  a  few  drops  of  colorless  liquid  trickling  from  the  meatus 
and  resembling  submaxillary  saliva.  At  other  times  they  believe  them- 
selves attacked  by  spermatorrhœa  for  the  same  reason.  It  is  not  difficult 
to  convince  them  that  this  liquid  is  not  the  spermatic  fluid. 

Under  certain  circumstances  frequency  of  micturition  is  apt  to  lead 
directly  to  a  more  or  less  marked  degree  of  polyuria  :  whether  the  renal 
secretion  is  directly  solicited  by  the  continued  emptiness  of  the  bladder 
creating  a  sort  of  appeal  or  whether,  by  a  mechanism  already  described, 
the  subject  drinks  a  great  quantity  of  liquid  to  overcome  his  pollakiuria. 
But  these  polyurias  caused  by  pollakiuria  are  never  very  abundant.  The 
quantity  of  urine  rarely  passes  two  quarts  or  two  quarts  and  a  half. 

Pains  are  extremely  frequent,  either  occurring  alone  or  associated 
with  other  manifest^^tions.  They  bear  no  direct  relation  to  micturition 
and  are  more  generally  located  in  the  region  of  the  membranous  urethra. 
They  are  apparently  connected  with  the  painful  contraction  of  the 
striated  sphincter.  They  are  felt  subjectively  in  the  form  of  a  sen- 
sation of  tension  and  fulness.  Objectively  they  are  augmented  by  pres- 
sure and  the  passage  of  a  sound  in  the  region  of  the  membranous 
urethra. 

But  urethral  pains  are  not  the  only  ones  which  may  be  experienced 
by  these  patients.  There  are  various  shooting  sensations,  sometimes  in 
the  lumbar  region  but  more  often  in  the  subumbilical  region.  Sometimes 
they  also  produce  true  vesical  pains.  In  certain  of  these  patients  even 
the  bladder  itself  may  under  some  circumstances  become  painful  to 
pressure.  This  is  generally  true  in  poUakiuric  individuals  who  have,  so 
to  speak,  educated  their  vesical  sensibility,  and  whose  bladder  has  be- 
come more  and  more  intolerant  and  more  and  more  painful  by  a  purely 
mental  mechanism.  This  association  of  the  vesical  phenomenon  with 
pollakiuria  creates  the  false  cystitis  of  which  we  have  had  the  oppor- 
tunity of  seeing  a  certain  number  of  examples.  It  was  thus  that  dur- 
ing a  number  of  weeks  we  had  in  the  Pinel  "Ward,  in  our  service,  a 
patient  who  complained  of  this  association, — imperative  pollakiuria  and 
vesical  pains.  The  starting-point  was  medical  in  its  nature.  This 
patient,  being  preoccupied  with  the  condition  of  her  genital  regions,  on 
account  of  marital  reasons,  had  consulted  a  physician,  who,  before 
examining  her,  and  suspecting  an  anteversion  which  he  could  not  have 
established  objectively,  had  questioned  the  patient  upon  the  frequency 


56  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

of  her  urination.  This  was  sufficient  to  make  the  patient  fix  her  atten- 
tion upon  the  region  of  her  bladder.  She  at  first  experienced  simple 
pollakiuria,  then  imperative  micturition,  and  finally  painful  sensations 
in  the  lower  abdomen.  It  is  useless  to  add  that  the  examinations  of  the 
urine,  being  completely  negative,  confirmed  the  purely  functional  nature 
of  the  manifestations  experienced. 

We  have  often  noted  phenomena  of  the  same  kind  in  women  who, 
suspecting  their  husbands  and  living  in  fear  of  being  contaminated  by 
gonococci,  experience  in  regular  progression  the  whole  series  of  symptoms 
which  we  have  just  indicated. 

In  the  same  way  with  men,  we  have  seen  them,  after  suspicious  con- 
tact and  without  any  urethral  discharge,  work  up  symptoms  of  the 
same  kind,  the  patient  fearing,  he  tells  us,  that  he  has  directly  in- 
fected his  bladder.  This  in  fact  is  a  type  of  false  urinosis  which  is  not 
rare,  but  which  is  very  little  known  and  which  one  finds  in  men  as 
well  as  in  women. 

The  disturbances  of  micturition,  properly  so  called,  on  the  contrary, 
are  exclusively  the  prerogative  of  men. 

Mr.  X.,  fifty-two  years  of  age,  a  pronounced  neurasthenic,  complained 
of  urinary  troubles  characterized  by  the  emission  of  urine  in  a  con- 
tinually interrupted  stream.  All  his  micturitions  as  long  as  they  lasted 
acted  in  the  same  way  as  would  be  normal  for  the  last  few  drops.  Our 
patient  had  had  urethritis.  He  was  afraid,  before  any  symptoms 
appeared,  of  being  threatened  with  a  stricture.  What  had  happened 
in  his  case?  Careful  observation  enabled  us  to  trace  the  mechanism 
of  the  phenomenon.  Obsessed  by  the  idea  of  having  a  full  and  normal 
stream  of  urine,  our  patient  contracted  with  extreme  intensity.  He 
contracted  not  only  his  abdominal  walls  but  also  his  membranous 
sphincter,  and  the  result  was  such  that  his  urine  would  only  run  when 
the  contraction  ceased  by  the  exhaustion  of  the  muscular  contraction. 
The  same  thing  would  begin  again  and  the  jet  stopped,  to  go  on  again 
when  it  was  again  exhausted,  and  so  it  would  continue,  whence  the 
prolonged  and  spurting  micturitions,  which  had  more  and  more  firmly 
rooted  in  the  patient's  mind  the  conviction  that  he  was  attacked  by  some 
unknown  urethral  affection  which  they  did  not  want  to  tell  him  that 
he  had. 

We  have  seen  patients  of  this  kind  the  victims  of  errors  of  diagnosis. 
As  the  phenomena  were  naturally  more  marked  when  the  bladder  was 
full,  it  followed  as  a  result  that  the  patients  complained  chiefly  of  diffi- 
culty on  awaking  in  the  morning.  They  were  therefore  treated  as 
prostatics,  while  they  were,  in  reality,  false  prostatics. 

We  have  seen,  however,  a  very  great  number  of  another  kind  of 
false  prostatics.  They  were,  it  must  be  confessed,  the  victims  of  medical 
therapy.  They  were  patients  of  a  certain  age  who  had  shown  some  one 
of  the  urinary  functional  manifestations  which  we  have  just  described. 
The  physician  naturally  thought  of  hypertrophy  of  the  prostate  and 


MANIFESTATIONS  IN  THE  URINARY  ORGANS.  57 

treated  it  accordingly.  More  particularly  have  we  seen  patients  who 
imagined  that  they  could  not  exist  without  regular  massage  of  their 
prostates.  As  a  matter  of  fact,  these  patients  were  purely  prostatic 
phobies,  made  so  as  a  result  of  medical  suggestion. 

We  have  described  separately  the  different  symptoms  which  false 
urinaires  may  present.  It  goes  without  saying  that  these  manifestations 
may  be  associated  one  with  another,  to  constitute  the  most  varied  as 
well  as  the  most  variable  syndromes..  It  is  all  a  question  of  attention, 
of  interpretation,  of  medical  suggestion  and  auto-suggestion,  or  again  a 
question  of  education.  If  we  bear  in  mind  that  under  the  effect  of  an 
emotion  all  these  elements  constitute  the  factors  of  urinary  functional 
localizations,  and  that,  on  the  other  hand,  a  mental  representation  is 
quite  as  susceptible  as  an  emotion  to  lead  up  to  spasmodic  phenomena, 
we  shall  have  finished  with  the  study  of  false  urinaires  having  treated 
the  subject  rather  briefly  because  the  majority  of  the  phenomena  which 
are  met  in  it  have  already  been  described  in  the  masterly  study  of 
Pr.  Guyon  (1889). 


CHAPTER  III. 

FUNCTIONAL    MANIFESTATIONS    OF    A    GENITAL    NATURE. 

Manifestations  of  this  kind  are  extremely  common  in  both  the  sexes. 
According  to  our  personal  experience,  they  are  almost  as  frequent  as  the 
digestive  manifestations,  whether  the  genital  localization  is  of  first  im- 
portance in  the  neuropathic  condition,  and  is  predominant  in  the 
symptomatology  constituting  what  has  been  called  sexual  neuras- 
thenia, or  whether  it  is  associated  with  other  preeminently  morbid 
manifestations. 

As  a  matter  of  fact,  it  is  comparatively  rare  for  a  neurasthenic, 
when  questioned  about  this  matter,  not  to  confess  to  some  troubles  of 
this  nature  if  willing  to  unbosom  himself  at  all.  But  it  must  be  added 
that  very  often  one  must  tactfully  draw  from  the  patient  a  confession 
of  the  existence  of  these  manifestations,  which,  from  a  sort  of  feeling 
of  shame  or  mistaken  self-respect,  he  is  often  reluctant  to  tell  about. 
And  if  this  is  true  for  men,  it  is  still  more  often  true  in  the  case  of 
women,  in  whom  sexual  functional  manifestations  are  much  more  fre- 
quent than  is  generally  supposed,  but  which  are  also  generally  very 
carefully  dissimulated. 

This  question  of  genital  troubles  in  men  and  women  does  not  seem 
to  have  hitherto  received  sufficient  attention  from  physicians.  Too  often 
they  do  not  concern  themselves  with  it  at  all  in  questioning  neuropaths, 
and  too  often  also  they  dismiss  the  subject  as  a  negligible  quantity  or 
even  as  a  subject  for  passing  pleasantry.  Nevertheless,  when  one  sees 
the  unhappy  homes,  and  the  ruined  health  and  depressions  sometimes 
ending  in  suicide,  which  are  the  consequence  of  these  troubles,  physicians 
ought,  we  insist,  to  pay  the  most  careful  attention  to  them. 

We  shall  study  successively — 

A.  Genital  troubles  of  men. 

B.  Genital  troubles,  of  women. 

Finally  we  shall  study  in  a  special  paragraph — 

C.  Pseudo-gynœcological  manifestations  of  a  neuropathic  nature 
(false  uterine  or  false  pelvic  cases,  etc.) 

A.  Genital  Troubles  of  Men. — The  starting-point  of  all  functional 
manifestations  of  this  nature  lies  in  the  psychic  fixation  of  the  subject 
on  his  genital  organs.  The  very  mechanisms  of  this  fixation  are  ex- 
tremely variable.  And,  without  pretending  by  any  means  to  give  all 
of  them,  we  shall  attempt  to  review  the  principal  among  them. 

Very  frequently  the  attention  of  the  individual  is  attracted  to  his 
genital  organs  by  what  might  be  called  venereo-  or  cyprido-phobia.  These 
58 


MANIFESTATIONS  OF  A  GENITAL  NATUEE.  59 

are  patients  who,  for  one  reason  or  another,  are  in  terror  of  having  con- 
tracted some  venereal  disease,  sometimes  because  they  have  had  sus- 
picious coitus,  and  sometimes  because  they  have  noticed  an  herpetic 
eruption  on  their  genital  organs  or  a  small  eczematous  patch,  or,  be- 
cause they  have  not  been  sufficiently  taught  in  matters  of  necessary 
cleanliness,  they  have  had  a  slight  balanitis.  Sometimes,  without  any 
physical  reason  whatsoever  and  merely  because  they  have  felt  some 
general  disturbance,  they  imagine  that  they  must  have  contracted 
syphilis,  and  from  that  time  on  they  examine  themselves  daily  for  any 
genital  manifestations.  One  sees  chaste  young  men  really  obsessed  in 
this  way,  sometimes  suffering  perfect  agony  by  imagining  that  they 
may  have  contracted  syphilis  by  contact  with  an  unclean  seat  or  vessel. 

From  that  time  on  these  patients  pass  their  time  examining  them- 
selves. If  they  fear  urethritis,  they  have  themselves  sounded  if  they 
pass  either  a  drop  of  urine  after  micturition  or  a  little  urethral  or 
prostatic  fluid.  And  just  as  such  men  will  later  pass  easily  over  into 
false  urinosis,  they  can  also  develop  sexual  neurasthenia  properly  so 
called.  If  they  fear  syphilis,  they  often  succeed,  by  repeated  examina- 
tions and  lavages,  in  creating  irritative  lesions  which  still  further  fix 
the  idea  in  their  minds  that  they  are  syphilitic,  and  then  they  conjure 
up  a  whole  series  of  ideas  concerning  the  exhausting  effects  of  syphilis. 
Believing  themselves  to  be  contaminated  in  some  way,  they  are  afraid 
of  contaminating  others.  Then  every  genital  symptom  may  follow  in 
the  wake.  These  patients  are  legion.  Urinary  specialists  and  syphil- 
ographers  know  them  well.  They  form  a  large  part  of  their  customary 
clientèle. 

Onanism  also  plays  an  important  part  in  the  fixative  mechanism.  Its 
rôle  is  by  no  means  physical,  for,  taking  it  all  in  all,  masturbation,  if 
not  practised  by  the  very  young,  of  course,  nor  too  frequently,  has  only 
psychic  consequences.  Sometimes  there  are  patients  who,  through  prac- 
tising masturbation,  have  taken  a  sort  of  distaste  to  the  sexual  act. 
Sometimes,  and  much  more  often,  individuals  who  have  masturbated, 
even  though  very  rarely,  have  become  convinced  that  they  have  done 
their  body  some  incurable  damage,  and  that  they  will  be  henceforth 
and  forever  weakened  and  impotent.  The  cause  of  this  lies  evidently 
in  the  education  intended  to  warn  the  young,  which  has  put  into  the 
patient's  mind  a  whole  series  of  erroneous  ideas  on  this  subject.  But 
it  is  sometimes  these  very  ideas  which  spoil  their  lives  for  them. 

But  much  more  often,  by  virtue  of  moral  or  religious  training,  they 
have  felt  a  sense  of  disgrace  from  the  beginning  of  their  masturba- 
tion, and  this  perpetual  state  of  self-reproach  has  finally  produced  in 
them  a  depressed  condition  which,  of  itself,  is  the  true  cause  of  their 
sexual  impotence. 

Neither  the  loss  of  a  certain  quantity  of  spermatic  fluid  in  mas- 
turbating nor  the  nervous  exhaustion  which  a  young  man  experiences 
will  weaken  him,  it  being  of  course  thoroughly  understood  that  the  act 


60  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

is  not  too  often  repeated,  if  he  does  not  combine  with  it  the  idea  of 
moral  reproach  or  a  fear  of  physical  exhaustion,  a  fear  which  is  at 
present  quite  too  common  and  which  is  encouraged  by  conversation  or 
by  reading  the  vast  literature  on  onanism  and  its  dangers.  We  have 
seen  cases  of  this  kind  in  men  from  thirty  to  fifty  years  of  age,  and 
even  still  older,  living  with  this  impression  that  by  reason  of  having 
masturbated  in  their  youth  they  had  dwarfed  and  devitalized  their 
organs  in  a  definite  manner,  and  that  they  were  still  paying  the  con- 
sequences of  their  bad  habits. 

By  reason  of  having  convinced  themselves  of  their  general  in- 
feriority, these  patients  are  very  apt  to  be  persuaded  concerning  their 
special  inferiority,  and  in  this  way  become  sexual  neurasthenics.  We 
have  seen  lamentable  shipwrecks  of  this  nature,  men  who  have  given  up 
the  idea  of  marrying  because  they  were  convinced  that  on  account  of 
their  masturbation  they  would  be  unable  to  procreate  or  that  their 
children  would  not  be  born  living  or  normal. 

'  By  an  analogous  mechanism,  sexual  excesses  may  come  in  as  factors 
of  sexual  neurasthenia.  At  some  period  in  their  life  certain  individuals 
may  have  indulged  too  repeatedly  in  coitus.  As  a  natural  consequence, 
they  have  experienced  a  certain  normal  fatigue.  But,  according  to  the 
degree  of  their  impressionability,  they  begin  to  consider  themselves 
irreparably  weakened,  as  much  in  their  general  health  as  in  their  special 
vitality.  We  saw  a  man  of  this  kind  who  was  fifty-two  years  of  age, 
of  a  remarkably  good  constitution  and  in  perfect  health,  but  who  sud- 
denly fell  into  a  state  of  sexual  neurasthenia  as  the  result  of  a  con- 
versation with  a  physician.  This  man  had  had  daily  coitus  since  he 
was  young,  but  his  physician  gave  him  to  understand  that  it  seemed  to 
him  rather  excessive  to  maintain  his  genital  activity  with  the  same 
degree  of  energy  in  his  sixth  decade.  And  this  individual,  hitherto 
in  perfect  health,  became  neurasthenic,  with  genital  manifestations,  be- 
cause he  feared  that  he  might  have  exhausted  himself  and  have  un- 
wittingly compromised  his  old  age,  and  also  because  he  thought  that  his 
careless  excesses  of  other  days  could  not  have  been  without  special 
deleterious  influence  upon  his  genital  functions. 

It  sometimes  happens  that  a  man  has  at  some  time  in  the  course  of 
his  existence  indulged  in  sexual  excesses.  Years  may  have  passed  with- 
out his  having  felt  any  consequences  of  them.  He  would  not  think  of 
them  again  did  not  some  sexual  trouble  arise,  but  he  then  begins  to 
remember  these  excesses,  systematizes  his  symptoms  around  them,  and 
attributes  his  trouble  to  their  far-off  effects. 

At  other  times  emotion  alone  is  the  cause  of  it.  This  is  the  case, 
for  example,  in  certain  chaste  individuals  who  on  marrying  ^'know 
nothing  or  dare  nothing.''  These  are  they  whom  Montaigne  describes 
as  being  as  helpless  as  a  tongue-tied  orator.* 

*  Montaigne's  witty  simile,    *'  Taiguillette  nouée,"  is  meaningless  in  a  literal 
translation. 


MANIFESTATIONS  OP  A  GENITAL  NATURE.  61 

In  other  cases  genital  sjTnptoms  are  brought  about  by  means  of 
mysticism  or  remorse. 

Then  again  a  simple  nocturnal  pollution,  which  could  perfectly  well 
be  explained  as  a  result  of  absolute  continence,  is  the  starting-point  of 
the  sjonptom.  The  patient  is  filled  with  remorse  because  he  has  had  a 
rather  voluptuous  dream  accompanying  his  pollution.  He  imagines  him- 
self to  have  taken  a  more  or  less  voluntary  part  in  it.  We  have  seen 
patients  of  this  kind  who  were  most  miserable,  leading  an  impossible 
existence  and  suffering  the  deepest  contrition  for  facts  of  this  kind. 
Sometimes  the  patient  has  more  definite  reasons  for  reproaching  himself. 
He  has  not  been  able  to  resist  a  very  strong  temptation,  and  he  becomes 
obsessed  because  he  has  broken  the  rules  of  chastity. 

In  other  circumstances  matters  become  more  complicated.  The  per- 
son has  more  or  less  deliberately  made  up  his  mind  to  yield  to  the 
*' temptations  of  the  flesh."  But  at  the  psychological  moment  the  in- 
tervention of  religious  ideas  has  exerted  an  inhibitory  action.  Some- 
times he  looks  upon  the  intervention  of  this  idea  as  providential,  but 
at  other  times  he  will  add  to  his  feelings  of  reproach  and  remorse  the 
conviction  that  he  is  impotent,  and  he  wiU  become  subject  to  a  sexual 
obsession  with  all  the  consequences  of  such  a  mental  condition. 

Now  we  come  to  the  long  category  of  patients  in  whom  sexual 
neurasthenia  is  established  as  a  result  of  transitory  impotence,  which 
in  itself  is  related  to  obsessive  preoccupation  or  an  emotion  or  some- 
times even  a  simple  state  of  fatigue.  The  desire  to  succeed  too  well,  the 
fear  of  failure,  or  some  association  of  ideas  which  refuses  to  be  banished, 
give  us  the  whole  mechanism  by  means  of  which  patients  may  fall 
headlong  into  sexual  neurasthenia,  for  the  reason  that,  if  they  have 
once  failed  in  the  act,  they  will  henceforward  in  all  successive  acts 
remember  it  and  be  troubled  by  it.  The  emotion  of  the  first  attempt, 
any  rather  considerable  excitement,  the  nervous  dread  of  being  sur- 
prised, the  fear  of  scandal  and  its  consequences,  the  fear  of  pregnancy, 
the  memory  of  a  former  mistress,  or  of  a  dead  wife  whom  the  present 
one  with  whom  he  is  having  the  experience  recalls  too  vividly, — any  one 
of  these  may  serve  as  a  means  by  which  the  initial  genital  localizations 
are  established.  Sometimes,  again,  it  wiU  be  the  too  overwhelming  desire 
to  awaken  a  little  warmth  in  a  partner  who  is  too  cold.  We  have  seen 
numerous  examples  of  every  one  of  these  conditions. 

By  an  analogous  mechanism,  under  the  influence  of  real  physical 
malformations  or  those  which  are  purely  theoretic,  another  large  class  of 
patients  may  develop  sexual  neurasthenia.  Here,  for  example,  is  the 
case  of  two  young  foreigners  living  in  a  country  where  the  boys  were 
accustomed  to  bathe  naked.  The  idea  came  to  them  to  examine  one 
another,  and  they  found  that  they  were  not  formed  in  identically  the 
same  fashion.  It  was  a  question  of  size  and  dimension.  Prom  that  they 
hastily  concluded  that,  not  being  strictly  alike,  they  were  probably 
both  of  them  malformed.    They  both  became  sexual  neurasthenics. 


62  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

Sometimes  the  existence  of  a  phimosis,  and  sometimes  the  influence 
of  a  more  or  less  careless  circumcision  that  has  left  a  slightly  painful 
cicatrix,  will  serve  as  the  starting-point  of  psychic  fixation. 

Under  other  circumstances  it  is  as  a  result  of  a  real  genital  disease, 
a  blennorrhagia,  an  orchitis,  or  any  other  venereal  affection,  that  the 
idea  of  possible  sexual  incompetence  gradually  penetrates  the  mind  of 
the  patient.    The  symptoms  soon  follow. 

Unwholesome  conversations  or  reading  may  also  play  the  same  rôle, 
and  draw  the  attention  of  an  individual  to  some  genital  pseudo-anomaly. 
In  addition  to  these  we  have  seen  sexual  neurasthenia  develop  in  men 
who  were  comparatively  old,  in  whom  the  loss  of  power,  being  purely 
relative,  was  quite  normal.  They  could  not,  however,  get  rid  of  the 
idea  that  they  were  failing,  and  symptoms  of  depression  with  genital 
localizations  followed. 

Finally,  other  individuals,  though  feeling  themselves  more  or  less 
weakened,  still  retain  an  instinctive  desire  for  the  sexual  act,  combined' 
with  a  reflex  fear.  They  look  upon  the  sexual  act  as  depressing  and 
fatiguing,  and  when  they  yield  to  it  are  conscious  of  a  feeling  of  the 
danger  connected  with  it,  and  from  that  may  result  under  some  cir- 
cumstances functional  difficulties  which  fix  the  patient's  mind  on  his 
genital  organs. 

Genital  localizations,  whatever  may  be  the  psychological  mechanism 
in  any  particular  case,  always  result  from  the  same  pathological 
physiology.  The  series  of  reflexes  of  which  copulation  and  ejaculation 
are  the  goal  may  be  put  into  play  by  simple  mechanical  excitation.  But 
the  part  that  the  psychism  plays  is  considerable,  for  we  know  that 
without  any  peripherical  excitation  an  erection  may  take  place  under 
the  influence  of  a  desire,  a  story,  a  conversation,  the  association  of  ideas, 
a  memory,  etc.  Under  these  conditions  the  ejaculation  itself  may  be 
provoked  by  simple  mental  representations.  Inversely,  there  exist 
numerous  psychic  images  which  are  able  to  inhibit  genital  reflexes. 
Emotion  has  a  very  distinct  inhibitive  action  of  this  kind.  One  can 
thus  conceive  how,  if  preceding  or  during  the  sexual  act  there  should 
intervene  any  emotional  manifestation  or  psychic  obsession  which  should 
in  some  way  divert  a  person's  mind  from  the  act,  it  might  be  rendered 
impossible.  Keciprocally  one  can  see  that  under  the  influence  of  ex- 
citement or  too  great  psychic  tension  the  successive  reflex  phenomena 
of  the  sexual  act  might  be  hurried  along  too  quickly,  and  that  numerous 
disturbances  might  result. 

These  various  considerations  bring  us  to  the  clinical  study,  properly 
so  called,  of  genital  fixations. 

These  symptoms  occur  in  all  ages,  but  they  are  more  especially  met 
with  in  young  men  at  the  beginning  of  their  sexual  life,  and  in  com- 
paratively old  men  at  that  period  which  one  might  describe  as  the 
masculine  menopause.  In  other  words,  it  is  at  the  time  when  the  functions 
begin  and  at  the  age  when  they  are  disappearing  that,  for  reasons  which 


MANIFESTATIONS  OF  A  GENITAL  NATURE.  63 

are  very  evident  after  what  we  have  just  said,  those  conditions  are  more 
apt  to  be  found  which  permit  the  genesis  of  genital  fixation. 

As  to  these  genital  disturbances,  they  are  of  extremely  diverse  nature. 
We  shall  study  them  first  analytically. 

The  most  common  of  all  the  functional  genital  manifestations  is 
undoubtedly  spermatorrhœa.  It  generally  passes  through  a  series  of 
successive  stages.  A  description  of  the  following  case  will  enable  us 
better  to  understand  its  mechanism. 

X.  is  a  soldier  twenty  years  of  age  whose  family  persuaded  him  to 
become  engaged.  He  was  in  this  way  separated  from  a  mistress  to  whom 
he  had  been  a  most  faithful  and  devoted  lover.  At  first  he  began  to 
practise  masturbation,  during  which  the  mental  representation  of  his 
mistress  would  serve  as  the  psychic  stimulus.  Then,  under  the  influence 
of  dreams  reproducing  the  images  which  he  had  voluntarily  tried  to 
evoke  by  his  practice,  he  had  nocturnal  pollutions.  These  disturbed 
him  considerably  as  they  became  progressively  more  and  more  frequent. 
Accompanied  at  first  by  voluptuous  sensations,  they  got  to  the  point 
where  they  could  be  produced  without  any  mental  representation.  Later 
still,  the  patient  had  diurnal  pollutions,  consisting  of  the  involuntary 
loss  of  a  few  drops  of  seminal  fluid  in  the  day.  These  physical  phenomena 
were  accompanied  by  a  psychic  syndrome,  characterized  by  a  great 
general  depression,  and  chiefly  by  a  real  obsession  over  his  seminal 
losses. 

This  spermatorrhœa — which  must  not  be  confused  with  prostator- 
rhœa,  and  above  all  with  the  discharge  of  urethral  mucus,  which  is  a 
very  frequent  phenomenon  in  urinary  phobias — finds  its  motive  for 
continuing,  within  itself,  by  the  obsessive  impressions  which  it  causes, 
and  which  become  in  a  more  and  more  subconscious  way  the  starting- 
point  of  a  very  great  exaggeration  of  genital  reflectivity.  In  these 
patients  an  ejaculation  takes  place  at  the  slightest  mechanical  stimulus. 
We  have  seen,  as  an  illustration  of  this,  an  officer  who  got  to  the  point 
where  he  had  to  give  up  riding  horse-back  because  the  friction  of  the 
saddle  in  the  course  of  a  ride  of  a  few  hours'  duration  would  give  rise  to 
several  pollutions.  Another  of  our  patients  could  not  ride  in  a  carriage 
or  a  street-car  without  an  ejaculation. 

It  is  rare  that  these  local  phenomena  do  not  become  diffuse,  and 
that  the  neuropathic  manifestations  do  not  extend  beyond  the  genital 
region  and  pervade  the  general  state  '  of  health,  leading,  by  the  con- 
viction under  which  the  subject  is  laboring,  that  his  spermatorrhœa 
depresses  and  weakens  him,  to  a  condition  of  general  asthenia  and  more 
or  less  marked  depression. 

Another  form  of  genital  functional  localization  is  established  by 
what  we  might  call  partial  impotence. 

Mr.  X.,  aged  fifty-six  years,  was  attacked  with  a  very  peculiar  form 
of  impotence.  He  is  a  married  man  but  extremely  inconstant.  During 
the  last  two  years  his  legitimate  relations  have  been  natural  and  normal, 


64  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

and  it  has  become  quite  impossible  for  him  to  have  any  extra-conjugal 
relations.    What  has  happened  in  this  particular  case  ? 

When  the  symptoms  started,  our  man  was  extremely  taken  with  a 
woman  to  whom  he  had  been  assiduously  making  love  for  more  than 
six  months.  This  lady  showed  signs  one  day  of  weakening  her  resistance, 
but  gave  a  rendezvous  at  her  own  home  to  her  would-be  lover.  The 
latter,  fearing  to  be  surprised,  and  overcome  with  emotion  at  the  success 
for  which  he  had  not  dared  to  hope,  found  himself  inert. 

One  can  conceive  of  the  despair  of  the  unfortunate  man,  who,  be- 
ginning to  grow  old  and  fearing  definite  impotence,  rushed  off  to  pro- 
fessionals. But  his  efforts  never  amounted  to  anything,  because  the 
moment  that  association  of  ideas  recalled  to  him  his  recent  lack  of 
success  he  was  seized  with  a  peculiar  state  of  anxiety  which  inhibited 
the  sexual  act,  and  which  grew  progressively  more  intense  in  proportion 
as  his  fear  of  permanent  disability  became  more  fixed.  Nevertheless, 
during  this  whole  period  his  legitimate  relations,  which  it  is  true  were 
few  and  far  between,  remained  normal,  thus  proving,  in  an  almost 
experimental  way,  the  psychic  nature  of  these  manifestations. 

We  have  been  able  to  observe  another  case  of  the  same  kind,  under 
slightly  different  conditions. 

A  man,  forty-eight  years  of  age,  married  to  a  woman  only  a  little 
younger  than  himself,  and  who  had  reached  the  period  of  her  meno- 
pause, perceived  that  in  their  conjugal  relations  his  wife,  who  had 
hitherto  been  rather  voluptuous,  was  gradually  growing  more  and  more 
indifferent.  Instead  of  attributing  this  phenomenon  to  its  true  physio- 
logical reasons,  he  believed  himself  responsible  for  it,  and  in  order  to 
convince  himself  on  the  subject  he  tried  to  prove  himself  elsewhere. 
Naturally  he  could  not  do  this  without  arousing  a  whole  series  of 
emotional  phenomena,  which  we  might  easily  attribute  to  distraction  by 
observation.  Hence  his  impotence,  which  was  also  partial,  because  at 
home  his  sexual  relations  remained  normal.  Matters  did  not  progress 
very  well  with  this  last  patient,  who  was  somewhat  of  a  philosopher, 
for  owing  to  the  indifference  of  his  wife  he  simply  gave  himself  up  to 
absolute  chastity.  But  cases  of  this  kind  are  rare,  and  in  this  instance 
the  man  could  not  bear  to  admit  any  falling  off  in  his  powers  and  put 
himself  under  unnecessary  restraint.  Sexual  obsessions  frequently 
follow,  and  the  condition,  as  a  rule,  becomes  complicated. 

Another  manifestation  consists  of  premature  ejaculation.  This  is 
a  phenomenon  very  often  observed  among  neurasthenics.  It  consists  in 
the  production  of  a  very  rapid  ejaculation,  often  before  there  has  been 
any  chance  of  intromission,  the  latter  being,  moreover,  frequently 
hindered  by  insufficient  erection.  We  have  had  a  great  many  patients 
complain  of  this  phenomenon,  either  alone  or  associated  with  other 
genital  manifestations.  It  is  very  rare  to  find  it  at  the  beginning  of 
any  trouble.  More  often  it  follows  some  symptom  or  other  of  the  sexual 
life,  and  particularly  an  accidental  failure.    Tormented  by  the  fear  of 


MANIFESTATIONS  OP  A  GENITAL  NATURE.  65 

another  failure,  and  obsessed  by  the  desire  for  a  normal  sexual  relation, 
these  patients  work  themselves  up  into  a  great  state  of  sexual  excite- 
ment. They  prepare  themselves  for  coitus  a  long  time  in  advance.  They 
produce  in  themselves  as  it  were  a  sort  of  psychic  coitus,  and  the  first 
venereal  contact  is  enough  to  set  off  the  ejaculatory  reflex.  This  is 
apt  to  be  a  symptom  in  a  progressive  process  which  sometimes  ends  in 
absolute  impotence. 

Absolute  impotence  is,  as  a  matter  of  fact,  very  rare  as  a  neuro- 
pathic manifestation.  There  exist,  it  must  be  admitted,  cases  where 
the  subjects  cannot  effect  any  sexual  relation,  because  it  is  impossible 
for  them  not  to  associate  with  it  some  phenomenon  of  emotion  or 
obsession.  These  patients  are  capable  of  having  an  erection  under  the 
influence  of  psychic  excitement,  but  they  are  unable  to  profit  by  it, 
because  the  very  idea  of  the  sexual  relation  in  itself  or  with  any  par- 
ticular person  is  enough  to  make  it  fall.  The  following  cases  will 
furnish  us  examples  of  these  troubles. 

Here  is  a  young  man  who  had  become  engaged,  but  who  neverthe- 
less was  accustomed  to  go  to  prostitutes.  He  was  overcome  with  self- 
reproach,  which  followed  him  to  the  very  night  of  his  wedding  and 
rendered  him  helpless.  When  after  several  months  of  medical  treat- 
ment he  found  that  his  condition  was  in  no  way  improved,  he  became 
desperate  and  was  ready  to  commit  suicide,  for  no  one  had  ever  thought 
of  inquiring  into  the  moral  cause  of  his  condition. 

Here  is  another,  and  it  is  a  very  common  case,  of  an  accidental 
weakness  followed  by  continuous  impotence.  One  day  one  of  us  met, 
rushing  into  his  office  like  a  whirlwind,  a  vigorous  young  man  whom  he 
had  treated  a  few  years  before  for  a  slight  attack  of  neurasthenia.  "I 
am  lost,"  he  cried.  ''I  have  no  longer  any  manhood;  I  can  no  longer 
have  conjugal  relations.  I  have  a  very  good  erection,  but  the  moment 
that  I  am  in  position  I  see  by  my  wife's  face  that  she  is  convinced 
that  I  cannot  continue,  and  immediately  my  erection  falls.  I  am 
profoundly  unhappy."  This  condition,  which  had  lasted  for  several 
weeks,  came  as  a  consequence  of  a  failure  in  coitus  after  a  fatiguing 
day.  A  cure  was  very  easily  brought  about  by  advising  the  patient  to 
practice  coitus  in  complete  darkness. 

A  workman,  a  house  decorator,  who  was  young  and  vigorous,  was 
called  upon  to  exercise  his  pictorial  talents  at  the  house  of  a  kept 
woman,  who,  finding  him  to  her  taste,  proposed  to  him  certain  occu- 
pations which  though  possibly  quite  as  arduous  were  undoubtedly  more 
pleasurable  than  his  own.  Finding  himself  thus  in  luxurious  surround- 
ings, with  a  lady  whose  underclothes  were  more  fussy  and  complicated 
than  anything  he  had  known,  our  man  was  thrown  into  a  state  of 
nervous  incapacity.  That  was  all  that  came  of  it,  except  as  a  result 
he  became  intensely  neurasthenic,  with  vague  ideas  of  suicide. 

A  young  man  who,  being  a  bachelor,  had  never  had  any  reason  to 
complain  of  his  genital  functions,  married.  Everything  went  well 
5 


/ 


66  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

the  first  few  days,  then  in  the  third  week  he  became  absolutely  impotent. 
His  wife  was  the  cause  of  this,  for  she  expected  of  him  nothing  short 
of  the  labors  of  Hercules.  She  had  listened  to  her  young  married 
friends,  who  had  persuaded  her  that  a  husband's  affections  could  be 
measured  by  the  number  of  proofs  of  his  love  which  he  was  capable  of 
giving  daily.  Somewhat  credulous,  she  had  reproached  her  husband, 
who  nevertheless  had  conducted  himself  very  well,  of  not  loving  her 
often  enough  in  the  twenty-four  hours.  No  sooner  had  she  uttered  the 
remark  when  her  husband  found  himself  absolutely  helpless. 

Here  is  a  man  who  has  been  impotent  for  six  years,  because  he 
was  operated  upon  for  a  phimosis  too  short  a  time  before  his  marriage, 
and  the  first  approa<îhes  were  painful. 

Here  is  another  who  can  do  nothing  because  his  wife  at  the  be- 
ginning of  their  genital  life  «howed  excessive  resistance.  Another  has 
been  impotent  since  the  beginning  of  his  marriage, — that  is  to  say,  for 
ten  years, — ^because  his  wife  suffered  too  much  at  the  first  approaches. 
His  erection  collapses  at  the  moment  of  intromission.  The  family  of 
his  wife  demanded  a  divorce  because  she  had  remained  virginal.  To 
show  that  he  was  not  impotent  in  the  true  sense  of  the  word  and  not 
wishing  a  divorce,  the  husband  practised  coitus  with  a  prostitute  before 
witnesses. 

A  third,  a  widower,  became  impotent  because  the  mistress  whom  he 
had  chosen  bore  an  astonishing  resemblance  to  his  first  wife.  When  he 
was  near  her  he  would  have  erections,  but  at  the  moment  of  practising 
the  act  his  erection  would  fall,  even  though  on  the  same  day  he  could 
practise  coitus  with  a  prostitute.  That  was  because  with  the  latter  he 
had  no  inhibitory  obsession  nor  remorse. 

The  following  case  demonstrates  very  plainly  how  strong  may  be  the 
influence  of  remorse.  A  man  thirty  years  of  age,  who  is  very  vigorous, 
and  who  had  often  proved  that  he  possessed  normal  genital  power, 
asked  the  hand  of  a  girl  with  whom  he  was  deeply  in  love.  The 
engagement  lasted  for  several  months,  when  one  day  being  overcome 
by  his  need  he  went  to  a  prostitute,  but,  feeling  that  he  was  behaving 
very  badly,  he  could  do  nothing.  Haunted  by  this  first  failure  and 
believing  himself  impotent,  he  tried  with  others,  and  quite  naturally 
one  failure  succeeded  another.  Disgusted  with  life  he  came  to  consult 
one  of  us  with  ideas  of  suicide.  He  was  told  to  hasten  his  marriage; 
but  he  could  only  decide  to  do  so  when  he  had  been  convinced  that,  in 
marrying  a  young  girl  who  was  ignorant  of  everything  and  who  could 
not  make  comparisons,  there  was  no  necessity  of  his  being  successful 
the  first  night,  while  if  he  married  a  widow  it  would  be  different. 
The  advice  succeeded  perfectly. 

Another  rather  rare  form  of  functional  manifestation  is  established, 
in  the  absence  of  any  other  trouble  and  in  spite  of  a  good  erection,  by 
the  impossibility  of  intromission.  In  these  cases  there  is  generally  to 
be  found  some  slight  organic  trouble. 


MANIFESTATIONS  OF  A  GENITAL  NATUEE.  67 

We  were  very  much  astonished  one  day  by  the  confession  made 
to  us  by  a  sexual  neurasthenic.  "Doctor,"  he  said,  "I  must  be  mal- 
formed; I  must  have  a  conical  penis  which  naturally  cannot  enter  a 
woman's  cylindrical  vagina.  It  is  impossible  for  me  to  have  more  than 
a  slight  intromission  for  I  am  immediately  caught.  '  '  The  man  in  ques- 
tion had  been  circumcised,  and  showed  at  the  margin  of  the  frasnum  a 
slightly  painful  scar.  It  was  the  passage  of  this  scar  which,  causing 
a  slightly  unpleasant  sensation,  stopped  his  intromission  and  had  become 
the  starting-point  of  all  his  symptoms. 

Such  cases  may  be  very  infrequent,  but  they  ought  nevertheless  to 
be  known,  because  they  are  not  always  easy  to  diagnose. 

There  is  still  another  genital  disturbance  among  neurasthenics  to 
which  we  desire  to  call  attention.  It  is  the  absence  of  complete  ejacula- 
tion in  spite  of  a  good  erection.  We  do  not  mean  by  this  its  delay, 
which  may  be  sometimes  more  and  sometimes  less,  according  to  the 
psychism  of  the  subject, — a  phenomenon  that  is  by  no  means  common 
in  neurasthenics,  who,  as  a  rule,  have  a  rapid  ejaculation, — but  its  total 
absence.  This  is  a  difficulty  which  we  have  had  a  chance  to  observe  on 
only  one  occasion.  It  occurred  in  a  man  thirty-eight  years  of  age, 
in  perfect  health,  who,  having  remained  chaste  on  account  of  his 
religious  convictions,  married  at  the  age  of  thirty-seven.  He  practised 
coitus  quite  normally,  but  never  succeeded  in  having  an  ejaculation, 
and,  after  having  made  every  effort,  often  for  an  hour  at  a  time,  he 
would  withdraw  still  in  erection  without  having  succeeded.  The  start- 
ing-point of  this  had  been  a  vaginal  hypersesthesia  of  his  wife  at  the 
beginning  of  their  marriage.  The  husband  would  begin  coitus,  then 
at  the  end  of  a  moment  would  withdraw  without  having  had  time  for  an 
ejaculation.  When  the  vaginismus  had  disappeared,  the  habit  of  not 
achieving  had  become  fixed.  A  month's  separation  of  this  couple  caused 
the  phenomenon  to  disappear. 

Finally,  there  is  a  large  class  of  patients  who  become  impotent  by  a 
wholly  different  mechanism.  Here,  properly  speaking,  it  is  a  question 
of  manifestations  of  a  very  special  kind,  belonging  rather  to  mental 
difficulties  than  to  neuropathic  troubles  properly  so  called.  We  allude 
to  the  whole  category  of  sexual  inverts  who  by  abnormal  mental  repre- 
sentations succeed  in  incompletely  inhibiting,  by  means  of  the  distaste 
which  they  gradually  acquire  for  the  normal  sexual  act,  the  whole 
series*  of  reflexes  which  produce  it.  These  patients  do  not  come  within 
the  scope  of  our  study  except  when  occasionally  they  are  impressed 
beyond  all  measure  with  their  very  special  impotence,  or  when  they 
develop  some  abnormal  manifestations  of  sexual  life.  We  have  seen 
extremely  severe  neurasthenic  conditions  develop  in  sexual  inverts  of 
this  kind. 

Along  with  these  patients  we  have  seen  others  in  whom  the  sexual 
relations  cause  only  the  very  faintest  voluptuous  sensations.  Such  a 
phenomenon  seldom  exists  alone,  but  is  generally  associated  with  other 


68  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

functional  manifestations.  More  often  the  voluptuous  sensation  is  in- 
hibited by  the  preoccupation  of  the  subject  concerning  the  mechanical 
conditions  of  his  sexual  relation. 

And  this  brings  us  to  inquire  how  these  various  manifestations  which 
we  have  just  described  group  themselves  or  follow  one  another  in  the 
same  individual. 

As  a  rule,  patients  develop  sexual  neurasthenia  in  two  different 
ways.  Sometimes  it  is  by  the  mechanism  of  spermatorrhœa  ;  sometimes, 
and  more  often,  it  is  because  an  attempt  at  coitus  has  ended  in  failure. 
But  when  one  takes  up  the  question  of  the  condition  itself,  one  finds  one- 
self in  the  presence  of  a  morbid  syndrome  of  which  spermatorrhœa  is 
often  an  element.  Urinary  manifestations  are  frequently  associated  with 
this  condition,  and  especially  all  the  troubles  of  micturition  as  well  as  the 
painful  symptoms  which  we  have  described  in  a  preceding  chapter.  As 
for  the  symptoms  of  impotence  which  are  associated  with  an  antecedent 
or  consecutive  spermatorrhoea,  they  are  progressive.  Although  at  the 
start  it  may  be  only  a  question  of  psychic  phenomena  by  emotional 
obsessions  which  have  temporarily  inhibited  the  reflex  genital  functions, 
yet  the  erections  rapidly  become  inadequate  and  accompanied  by  ex- 
tremely rapid  ejaculations. 

Concerning  the  relations  of  the  genital  functional  manifestations 
with  general  neurasthenic  conditions,  two  classes  of  facts  may  be 
observed. 

When  limited  to  the  too  rapid  ejaculations,  associated  or  not  with 
spermatorrhoea,  genital  localizations  are  very  frequently  met  with  in 
individuals  who  have  become  neurasthenic  for  reasons  which  have  no 
relation  to  the  genital  sphere.  The  genital  manifestations  may  in  these 
patients  become  the  starting-point  of  preoccupations,  and  superimposed 
obsessions,  which  continue  to  develop  and  aggravate  their  condition  ;  but 
their  rôle  as  a  pathogenic  factor  is  nil. 

In  many  other  circumstances  the  case  is  quite  different,  and  the 
genital  trouble  is  the  initial  phenomenon  from  which  a  consecutive 
neurasthenic  state  is  developed.  It  is  difficult,  in  fact,  to  realize  how 
much  upset  many  individuals  are  when  they  believe  that  their  virility  is 
attacked.  There  is  nothing  that  disturbs  them  more.  We  have  seen 
patients  by  whom  material  losses  and  very  deep  grief  were  treated  as 
hardly  worth  considering  in  comparison  with  the  importance  which  they 
attached  to  their  genital  afflictions.  It  would  seem  that  the  sexual 
function — which  is  in  fact  the  chief  function,  the  function  of  repro- 
duction and  perpetuity  of  the  race,  and  above  all  an  instinctive  function 
— could  not  be  touched  without  the  entire  personality  of  the  in- 
dividual being  affected  by  it.  Thus,  we  cannot  too  strongly  advise  the 
necessity  of  always  examining  the  neuropath  to  learn  the  condition  of 
this  function.  These  patients  are  sometimes  so  ashamed  of  the  troubles 
which  they  present,  because  they  feel  as  if  they  were  in  some  way 
humiliated  by  them,  that  they  are  very  apt  to  try  to  hide  them  from 


MANIFESTATIONS  OF  A  GENITAL  NATURE.  69 

the  physician.  This  is  a  characteristic  which  is  not  without  some  value, 
because,  as  a  rule,  the  opposite  is  true,  and  the  patient  is  only  too 
disposed  to  attribute  an  often  complex  symptomatology  to  his  genital 
localizations  alone. 

B.  Sexual  Manifestations  of  Women. — The  sexual  life  of  a  woman, 
although  it  is,  to  be  sure,  less  external  than  that  of  man,  may,  however, 
be  none  the  less  intensive  for  that.  For,  if  in  earher  times  physicians  at- 
tempted to  establish  a  relationship  between  the  female  genitals  and  the 
phenomenon  of  hysteria  (a  more  than  doubtful  relation),  it  must  have 
been  because  they  considered  as  frequent  in  women  certain  manifesta- 
tions bearing  some  resemblance  to  those  which  in  a  man  constitute 
sexual  neurasthenia.  Was  it  a  certain  reserve  on  the  part  of  the 
authors,  not  wishing  to  expatiate  upon  so  delicate  a  subject,  was  it 
because  physicians  discreetly  forbore  to  inquire  too  frequently  concern- 
ing these  things,  for  fear  of  offending  the  easily  awakened  modesty  of 
their  patients,  or  was  it  dissimulation  on  the  part  of  the  patients,  who 
wilfully  refused  to  explain  any  phenomena  of  this  nature  which  they 
might  experience? 

For  our  own  part,  from  our  personal  experience,  we  have  for  a  long 
time  been  convinced  not  only  of  the  great  frequency  of  these  troubles, 
but  of  their  extreme  importance  as  pathogenic  factors  in  a  great  variety 
of  neurasthenic  conditions.  This  is  the  more  easily  explained  because 
in  the  life  of  a  woman  the  sexual  function  holds  a  most  important 
place,  for  upon  it  depends  the  phenomenon  of  maternity. 

In  all  that  concerns  the  psychic  mechanism  itself  connected  with 
these  localizations,  a  very  important  part  must  always  be  attributed  to 
education.  We  have  seen  that  in  man  chastity  was  one  of  the  frequent 
causative  conditions  of  the  psychoneuroses  of  a  sexual  nature.  The 
fact  of  in  some  way  symbolizing  the  sexual  acts  or  of  subordinating 
them  to  moral  or  religious  conditions  has  as  a  consequence  the  result  that 
in  the  consummation  of  the  sexual  act  the  psychism  occupies  a  too 
important  place,  and  is  capable  of  singularly  modifying  physical  mani- 
festations. It  must  not  be  forgotten  that  the  sexual  act  is  the  most  in- 
stinctive phenomenon  of  organic  life,  and  that  aU  the  psychic  mani- 
festations which  are  added  to  it  are  supplementary,  useless,  or  dangerous. 
Therefore,  it  is  very  certain  that  as  far  as  woman  is  concerned  any 
education  touching  on  her  sexual  life  is  essentially  anti-instinctive. 
Every  effort  is  made  to  cultivate  in  her  a  sense  of  modesty,  and  to 
make  her  consider  her  sexual  manifestations  as  something  mysterious, 
we  might  almost  say  shameful.  A  young  girl  is  often  ignorant,  even 
at  the  moment  of  her  marriage,  of  what  the  sexual  relations  really  are. 
She  is  often  frightened  by  the  revelation  and  the  education  which  she 
has  received  is  frequently  of  such  a  nature  as  to  start  up,  apropos  of 
these  relations,  a  whole  series  of  emotional  and  psychic  phenomena 
which  are  peculiarly  liable  to  upset  her. 


70  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

We  by  no  means  think  that  free  course  should  be  given  to  the 
instinctive  tendencies,  nor  do  we  consider  abnormal  those  restrictions 
which  moral  and  social  considerations  bring  to  bear  upon  instinct.  Quite 
the  contrary.  But  we  do  hold  that  there  is  no  high  moral  strength 
w^here  there  is  ignorance,  anxiety,  or  emotion.  There  is  no  morality 
without  conscious  knowledge.  And  if  we  are  persuaded  on  the  one 
hand  that  all  the  methods  of  education  which  may  disturb  a  young  girl 's 
mind  are  bad,  and  if  we  know  on  the  other  that  in  certain  subjects 
ignorance  is  the  best  prophylaxis,  yet  we  are  none  the  less  convinced 
that  many  of  the  sexual  disturbances  which  have  spoiled  the  life  of  more 
than  one  woman  could  have  been  avoided  by  rational  education.  Should 
not  the  object  of  a  wise  education  be  to  harmonize  the  instinctive 
tendencies  of  individuals  with  the  rules  of  sound,  healthy  morality? 
Those  methods  of  education  which  try  in  some  way  to  annihilate  an 
instinct,  to  consider  it  as  non-existent,  and  to  make  one  think  that  all 
its  manifestations  are  immodest,  have  seemed  to  us  to  occur  frequently 
as  factors  of  the  genital  obsessions  which  we  have  had  the  opportunity 
to  observe  in  certain  women. 

The  whole  subject  resolves  itself  into  a  question  of  tact,  perception, 
and  the  right  moment.  It  is  very  certain  that  a  so-called  ''liberal" 
education  may,  from  this  point  of  view,  be  extremely  one-sided,  if  not 
dangerous.  If  certain  teachings  which  tend  to  take  no  notice  of  an 
instinct  that  ought  to  be  normally  exercised  in  life  are  unhealthy,  those 
teachings  which  exalt  it  and  pervert  it  are  still  more  to  be  feared.  An 
excessive  repugnance  or  a  too  marked  taste  are  the  opposite  poles,  each 
of  which,  according  to  our  way  of  thinking,  is  as  dangerous  as  the  other. 

It  is  a  fact  that  women  very  frequently  develop  sexual  neurasthenia 
when  they  first  begin  their  sexual  life.  The  part  which  defloration 
plays  in  the  development  of  genital  localizations  is  really  very  great. 
Sometimes  the  fault  belongs  wholly  to  the  partner,  who  is  clumsy,  either 
through  ignorance  or  brutality.  Sometimes  it  is  the  ignorance  of  the 
woman  which  causes  it  and  her  education  which  makes  it  repellent  to 
her.  She  is  horrified  with  everything  that  has  anything  to  do  with 
sexual  relations,  and  finally  gets  to  the  point  of  having  sexual  phobias. 
With  her  the  instinct  has  been  inhibited  by  her  education,  unless  the 
peculiar  circumstances  of  her  defloration  have  annihilated,  for  a  greater 
or  less  time  oy  even  completely,  the  natural  tendencies.  Sometimes  the 
instinct  or  desire  of  maternity  exists  even  when  the  coitus  instinct 
has  disappeared.  One  can  then  imagine  the  complication  in  her  psychic 
life  which  this  may  bring  about,  and  the  moral  break-down  which  may 
follow.  On  the  other  hand,  the  latter  may  be  the  direct  result  of  the 
disturbed  matrimonial  relations  to  which  such  manifestations  almost 
inevitably  lead.  It  sometimes  happens  that  the  union  is  brusquely 
broken  ;  it  also  happens  that  the  wife,  loving  her  husband,  tries  to  hide 
her  feeling  of  repulsion.  She  may  succeed  in  doing  this,  but  will  live 
in  continual  anguish,  which  cannot  be  without  more  or  less  immediate 


MANIFESTATIONS  OP  A  GENITAL  NATURE.  71 

influence  upon  her  moral  state.  In  the  most  fortunate  cases  she  may, 
after  a  certain  number  of  months  or  years,  accustom  herself  to  it  after  a 
fashion.  It  is  no  less  true  that  even  under  these  circumstances  the 
entire  course  of  her  life  may  have  been  misdirected  in  consequence. 

In  a  similar  way,  it  is  very  frequent  that  violences  inflicted  upon  a 
woman  become  the  only  too  legitimate  starting-point  of  very  serious 
genital  disturbances. 

Violation  as  an  accomplished  fact,  or  simply  attempted,  and  even 
simply  touching  the  organ  may  sometimes  make  such  a  strong  impression 
upon  the  victim's  mind  that  vigorous  mental  representations  may  spring 
up  which  are  susceptible  of  completely  modifying  the  sexual  life  of 
the  woman. 

Incomplete  coitus,  we  hold,  is  a  very  frequent  cause  of  sexual  troubles 
in  women.  Whether  it  be  a  question  of  real  physiological  disturbance 
accompanying  abnormal  practices,  or  whether  it  be  due  to  the  inter- 
vention of  the  phenomenon  of  attention  in  an  act  which  theoretically 
ought  to  be  free  from  it,  or  whether  it  be  remorse  for  an  act  contrary  to 
moral  laws, — any  one  of  these  factors,  either  alone  or  associated,  may  be 
more  or  less  predominant  according  to  the  individual. 

31ysticism  is  another  factor  of  these  same  manifestations.  Without 
insisting  too  strongly  upon  it,  we  think  that  it  is  by  means  of  mental 
restriction  which  it  introduces  into  a  physiological  act  that  its  inter- 
vention makes  itself  felt. 

Masturbation  may  also  be  the  starting-point  in  a  woman  of  more 
or  less  permanent  genital  disturbances.  Either  on  account  of  the 
uneasy  conscience  which  it  may  cause  in  subjects  who  are  inclined  to 
be  scrupulous,  or  by  having  introduced  young  persons  too  early  to  the 
sexual  life  to  which  they  then  yield  themselves,  it  gives  birth  to  a 
whole  series  of  mental  representations  with  the  phenomena  of  association 
of  ideas  and  comparisons  which  disturb  normal  sexual  activity. 

Sterility  is  responsible  for  a  number  of  cases  of  sexual  neurasthenia 
in  women.  Being  sterile  she  considers  herself  to  be  abnormal  and 
abased.  Often  she  is  reproached  for  her  sterility  by  those  around  her, 
and  she  becomes  obsessed  on  the  subject.  More  often,  to  tell  the  truth, 
these  patients  become  what  we  shaU  now  study  under  the  title  of  false 
sexualism. 

Inversely,  the  fear  of  pregnancy ^  this  great  modem  evil,  may  become 
the  starting-point  of  sexual  phobic  manifestations.  Its  rôle  is  much 
the  same  in  effect  as  that  of  incomplete  coitus. 

Frigidity  on  the  part  of  the  woman  is  at  the  same  time  a  cause  and 
an  effect.  From  this  poipt  of  view,  we  shall  study  it  with  the  clinical 
forms  of  functional  sexual  manifestations  in  women. 

All  the  mechanisms  that  we  have  just  glanced  at  have  an  essentially 
restrictive  action  on  the  sexual  life  of  the  woman.  She  may,  however, 
enter  upon  this  form  of  nervous  disease  by  a  wholly  different  path. 
As  a  matter  of  fact,  if  the  sexual  instinct  is  susceptible  of  being  in- 


72  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

hibited  by  certain  psychic  phenomena,  other  mental  representations  are, 
on  the  contrary,  capable  of  stimulating  it. 

In  this  sense  sterility  may  come  in  again.  It  is,  as  a  matter  of 
fact,  rather  rare.  More  frequently  the  abstinence  of  the  husband  is 
the  cause  which  deprives  a  woman  of  the  satisfactions  which  she  con- 
siders legitimate  and  concerning  the  absence  of  which  she  becomes 
obsessed. 

Age  may  also  have  something  to  do  with  it,  the  much-talked-of 
critical  age,  when  a  woman,  seeing  the  end  of  her  sexual  life  approach- 
ing, tries  to  make  the  most  of  her  last  years. 

Frigidity  may  also  come  in  in  this  latter  sense  as  well  as  in  the 
restrictive  sense,  the  woman  wishing  to  prove  to  herself  that  she  is  not 
abnormal.  We  are  not  speaking  now  of  sexual  perverts,  but  of  honor- 
able, sometimes  very  austere,  women  who  are  the  prey  of  obsessive  ideas 
against  which  they  struggle.  Often  their  ideas  do  not  take  shape,  but 
just  as  often,  being  depressed  by  these  obsessions,  they  fall  into  very 
grave  neurasthenic  conditions  of  all  kinds. 

We  have  now  reached  the  study  of  the  clinical  forms  under  which 
may  be  presented  sexual  functional  manifestations,  considered  in  them- 
selves or  in  their  consequences.    We  shall  take  up  successively — 

1.  Genital  localizations,  properly  so  called  (spasms,  contractures, 
algias) . 

2.  Feminine  frigidity. 

3.  Neurasthenic  states  of  sexual  origin. 

1.  True  Genital  Localizations. — These  localizations  may  be  of  two 
kinds.  One  set  corresponds  to  a  mental  representation  of  defence.  Such 
are  vaginismus  and  contraction  of  the  adductors,  which  may  occur  either 
alone  or  associated.  Others  correspond  to  the  externalization,  or  the 
projection  of  painful  representations  to  the  region  of  the  genital  organs. 
Such  are  genital  pains. 

These  two  kinds  of  genital  manifestations  may  be  complicated  by 
the  addition  of  urinary  phenomena,  increased  micturition,  pains  in  the 
bladder,  etc. 

Vaginismus  consists  of  a  painful  spasm  of  the  vaginal  muscles,  which 
takes  place  every  time  there  is  an  attempt  to  penetrate  into  the  vagina. 
Its  result,  we  might  almost  say  its  aim,  is  to  make  all  sexual  approach 
impossible. 

In  the  great  majority  of  cases,  the  origin  of  vaginismus  is  of  a 
sexual  nature.  It  occurs  as  a  consequence  of  clumsy  defloration,  or 
following  an  attempt  at  violation,  or  as  a  result  of  coitus  which  has  been 
painful  for  some  reason  or  other.  It  may  be  brought  about  by  simple 
emotional  fear  of  sexual  approach.  But  sometimes  the  mental  repre- 
sentation may  be  started  by  elements  of  a  physical  nature,  and  on  the 
frequent  existence  of  this  has  been  based  the  theory  of  vaginismus  or 
reflex  spasm.     It  is  certain,  in  fact,  that  in  many  cases, — and  very 


MANIFESTATIONS  OF  A  GENITAL  NATURE.      73 

naturally  so,  in  view  of  the  circumstances  under  which  vaginismus 
occurs, — there  exist  traumatic  or  inflammatory  lesions  of  the  genital 
organs  as  a  result  of  defloration.  These  lesions  may  be  painful  in 
themselves  or  on  contact,  and  may  enter  into  the  genesis  of  the  spasm. 

It  would  thus  be  the  initial  production  of  pain  that  would  determine 
the  spasm  at  the  moment  of  coitus.  This  perhaps  may  be  the  mechanism 
of  certain  forms  of  vaginismus, — superior  vaginismus, — where  a  certain 
penetration  is  possible  and  where  the  vaginal  contraction  takes  place 
only  in  the  upper  part.  Finally,  in  certain  cases  it  is  not  the  vagina 
itself  w^hich  is  hyperagsthetic,  but  only  the  clitoris.  " 

But,  as  a  general  rule,  in  all  these  cases  the  pain  is  due  to  a  psychic 
mechanism  and  has  nothing  to  do  with  any  previous  action  exerted 
on  the  painful  spot.  It  is,  therefore,  the  fear  of  pain  which  comes  into 
play.  It  is  thus  that  we  find  vaginismus  persisting  in  women  who  are 
morally  distressed  on  account  of  their  genital  inferiority  and  who  ask 
nothing  more  than  to  be  relieved  of  it.  One  sees  it  even  in  prostitutes  ! 
It  could  not  be  otherwise  w^hen  the  mechanism  of  vaginismus,  as  a 
rule,  causes  a  fear  of  the  sexual  act.  This  is  the  way  in  which  the  great 
majority  of  cases  become  established.  It  may  be  complicated  or  con- 
tinued by  one  of  the  secondarj^  mechanisms  which  we  have  just 
described,  such  as  anxiety  at  the  appearance  of  real  pain  due  to  lesions, 
or  uneasiness  caused  by  the  possible  memory  of  former  pains. 

Vaginismus  may  have  still  a  different  mechanism.  The  production 
of  too  strongly  voluptuous  sensations  or  a  too  intense  psychic  desire 
w^hich  is  afraid  of  missing  its  satisfaction  may  also  be  the  starting-point 
of  it.  This,  however,  is  a  very  much  rarer  form  of  vaginismus,  and  in 
such  cases  the  fixation  is  not  generally  lasting. 

Confirmed  vaginismus  is  a  very  painful  affection  ;  but  on  questioning 
patients  they  quickly  reveal  the  preponderating  mental  nature  of  this 
pain,  which  often  the  mere  approach  of  the  male  is  sufficient  to  elicit, 
and  sometimes  the  simple  idea  of  the  sexual  act  is  sufficient  to  cause  it. 
Sometimes  it  disappears  suddenly  without  any  apparent  cause.  Some- 
times a  change  of  partner  will  determine  its  disappearance.  More  often, 
and  if  it  is  not  treated,  it  is  a  lasting  affection.  We  have  seen  women 
who  remained  chaste  through  their  whole  life  on  account  of  vaginismus. 
It  goes  without  saying  that  their  conjugal  happiness  was  peculiarly 
compromised  in  consequence. 

A  girl  at  eight  years  of  age  when  playing  with  her  brother 
received  a  violent  blow  on  the  labia  majora.  She  told  nobody  about 
it,  but  believed  that  she  had  been  seriously  hurt.  As  she  grew  older 
there  gradually  grew  in  her  mind  the  idea  that  this  traumatism  had 
deformed  her  genital  organs.  She  was  frightened  at  anything  that  had 
to  do  with  the  functions  of  that  region.  When  she  heard  a  confine- 
ment spoken  of,  she  was  seized  with  a  feeling  of  terror.  Believing  her- 
self malformed,  she  made  up  her  mind  to  remain  unmarried,  but,  being 
very  unhappy   at  home,   she   did  marry  nevertheless  when   she   was 


74  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

twenty-six  years  of  age.  When  she  was  seen  by  one  of  us  six  years 
after  her  marriage,  she  had  never  yet  been  able  to  allow  her  husband 
to  approach  her,  and  no  physician  had  ever  been  able  to  examine  her 
on  account  of  the  foolish  terror  into  which  she  was  thrown  at  the  moment 
of  examination,  a  terror  which  manifested  itself  in  extreme  agony,  which 
almost  overcame  her,  as  well  as  on  account  of  the  invincible  defence  of 
the  adductors.  This  woman  was  all  the  more  broken-hearted  over  her 
condition  because  she  ardently  desired  to  have  a  child.  Isolation  was 
the  only  thing  that  had  any  effect  upon  these  symptoms,  and  when  this 
patient  was  convinced  that  she  was  normally  formed,  and  when  she  con- 
sented to  dilate  herself  gradually  by  means  of  sounds  which  were 
increased  in  size  by  degrees,  she  became  so  qualified  for  her  conjugal 
duties  that  ten  months  after  her  treatment,  which  had  lasted  two  months, 
she  became  a  mother.  By  the  progressive  dilatation  of  the  hymen, 
practised  by  the  patient  herself,  and  by  persuasion,  the  intense  hyper- 
esthesia which  she  had  experienced  on  the  entrance  of  the  vagina  had 
completely  disappeared. 

Contracture  of  the  adductors  may  exist  in  two  different  forms.  It 
is  sometimes  produced  in  an  intermittent  fashion  and  is  then  frequently 
associated  with  vaginismus.  This  spasm  of  the  adductors  occurs  under 
exactly  the  same  circumstances  as  vaginismus,  and  is  always  determined 
by  a  sexual  idea,  which  may  be  positive  as  well  as  negative.  As  a  rule, 
this  phenomenon  is  merged  into  the  symptom-complex  of  vaginismus. 
This  is  not  the  same  in  permanent  contracture  of  the  adductors.  The 
latter  may  be  found  in  hysterics  quite  apart  from  any  genital  causa- 
tion, as  may  be  any  other  muscular  contraction.  It  is  none  the  less 
true,  however,  that  in  the  large  majority  of  cases,  the  contracture  fol- 
lows a  sexual  fixation.  We  have  seen  contracture  occur  after  attempts 
at  violation  and  after  defloration.  The  fear  alone  of  sexual  approaches 
may  also  determine  it.  Sometimes  this  contracture  is  very  violent.  It 
is,  as  it  were,  the  crystallization  of  the  phenomenon  of  defence  which 
is  expressed  in  the  contracture  of  the  adductors, — custodes  virginitatis. 
Sometimes  a  greater  or  less  period  of  preparation  is  required  to  bring 
it  about,  as  is  the  case  in  many  hysterical  manifestations. 

When  it  takes  place,  the  limbs  of  the  patient  are  in  extreme  adduc- 
tion, and  the  knees  are  tightly  pressed  one  against  the  other.  Some- 
times one  member  overrides  the  other.  If  one  tries  to  separate  the 
limbs,  the  contracture  grows  worse,  and  one  can  feel  the  cord  of  the 
adductors,  just  as  plainly  as  if  it  were  a  case  of  an  organic  affection 
of  the  hip.  As  a  fact,  there  is  no  notable  difference  between  this  con- 
tracture of  psychic  origin  and  the  contracture  of  organic  origin  which 
may  lead  to  a  coxalgia  ;  in  either  case  it  is  a  question  of  phenomenon  of 
defence.  Here  it  is  defence  against  the  pain  which  movement  causes. 
There  it  is  a  defence  phenomenon  against  a  sexual  approach,  which, 
although  it  may  have  become  purely  imaginary,  is  none  the  less  capable 
of  producing  the  same  results.    In  both  cases  it  is  a  reflex  phenomenon, 


MANIFESTATIONS  OF  A  GENITAL  NATURE.  75 

with  a  peripheral  starting-point  in  the  contracture  of  organic  origin 
and  a  central  starting-point  in  the  neuropathic  contracture.  As  a 
matter  of  fact,  one  instinctively  defends  oneself  in  the  same  way 
against  a  danger,  whether  it  is  supposed  or  real.  This  is  a  very  in- 
teresting fact,  because  it  opens  up  a  vista  of  secondary  theoretic  con- 
siderations, which  we  shall  examine  a  little  later. 

Contraction  of  the  adductors  thus  created  does  not  tend  to  improve 
spontaneously.  It  may  last  for  a  very  long  time,  four  years  in  one  case 
observed  by  one  of  us.  It  may  disappear  under  the  influence  of  a 
strong  emotion.  It  is  susceptible  of  being  dispelled^  by  means  of  psycho- 
therapy. Does  it  persist  during  sleep?  This  is  a  question  that  we 
shall  take  up  when  we  study  hysterical  contractures  as  a  separate  sub- 
ject. We  might  note,  however,  that  its  non-persistence  during  sleep 
would  have  no  significance  in  modifying  our  conception  of  its  origin. 
As  a  phenomenon  of  defence  it  is  liable,  as  are  all  phenomena  of  defence, 
to  disappear  or  to  diminish  during  sleep.  Contractures  of  organic 
origin — such,  for  example,  as  those  of  coxalgia — persist  during  natural 
sleep,  because  the  pain,  which  gives  rise  to  them,  continues  even  during 
this  state  to  be  felt  in  a  subconscious  fashion.  They  disappear  during 
chloroform  anaesthesia,  as  do  hysterical  contractures,  because  in  the 
chloroform  slumber  the  painful  sensation  vanishes. 

This  contracture  of  the  adductors  is  generally  very  marked.  When 
it  is  not  so  severe,  it  may  give  rise  to  a  group  of  symptoms  creating 
hysterical  coxalgia;  but  we  shall  meet  all  these  questions  elsewhere,  so 
we  will  not  dwell  upon  them  now. 

Genital  algias.,  like  the  symptoms  which  we  have  just  described, 
are  generally  of  sexual  origin,  but,  though  they  may  be  increased  by 
the  manifestations  of  the  sexual  life,  their  peculiar  nature  is  that  they 
are  permanent  manifestations  which  become  in  some  way  autonomous. 

The  thought  of  physical  malformation,  painful  coitus,  a  rather 
profuse  leucorrhœa,  a  real  but  temporary  lesion,  may  be  the  origin  of 
the  psychic  fixation  of  a  painful  symptom  which,  whatever  its  source, 
ends  by  being  a  pain  of  purely  central  causation. 

In  certain  cases  the  pain,  which  is  most  frequently  localized  in  the 
vagina,  is  in  no  way  increased  by  contact  or  pressure.  Under  other 
conditions  it  would  seem  that  there  exists,  by  virtue  of  continued  mental 
representation,  a  sort  of  educated  sensibility,  an  erethism  of  painful 
sensibility,  which  causes  vaginal  sensibility  to  be  perceived  in  a  painful 
fashion.  Sometimes  simple  contact  then  becomes  extremely  painful, 
and  vaginal  pain  may  develop  or  maintain  the  symptoms  of  vaginismus. 

When  once  this  algia  is  developed,  it  becomes  an  obsession.  The 
patients  are  extremely  preoccupied  with  it.  By  reason  of  its  situation 
they  may  manage  to  hide  it,  and  refrain  from  complaining  about  it. 
Sometimes  they  are  perfect  martyrs  to  it. 

Yery  frequently  vaginal  algias  are  accompanied  by  urinary 
phenomena,  pollakiuria,  cystalgia,  etc. 


76  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

By  the  continued  preoccupation  which  they  set  up,  algias  are  apt 
to  react  upon  the  general  health  and  to  become  the  starting-point  of 
serious  neurasthenic  symptoms. 

2.  Female  Frigidity. — Female  frigidity  may  include  two  classes 
of  facts, — absence  of  sexual  desire  on  the  one  hand,  and  on  the  other 
absence  of  voluptuous  sensations.  In  reality  these  two  orders  of  mani- 
festations are  closely  allied,  and  we  shall  take  up  here  only  that  frigidity 
which  is  due  to  the  absence  of  voluptuous  sensation,  which  may  or  may 
not  eventually  lead  to  the  suppression  of  desire  for  coitus. 

This  is  a  rather  frequent  phenomenon,  which  is  very  little  under- 
stood and  is  looked  upon  as  of  no  importance,  but  which  nevertheless 
is  the  origin  of  all  kinds  of  troubles  •  which  react  upon  the  conjugal 
life,  and  even  upon  the  social  life  of  the  affected  persons. 

It  may  in  certain  cases  be  merely  apparent.  This  is  when  the 
inadequacy  of  the  partner  is  the  cause.  It  is  especially  apt  to  be  met 
with  when  the  man  is  himself  a  sexual  neurasthenic  with  extremely 
rapid  ejaculations.  We  shall  find  cases  like  this  further  on.  For  the 
present  we  shall  take  up  only  the  question  of  feminine  frigidity  in 
those  cases  where  the  husband  for  his  part  is  equal  to  the  occasion. 

There  are  no  voluptuous  phenomena  without  corresponding  mental 
representations,  and  as  a  matter  of  course  there  are  none  in  the  presence 
of  contradictory  mental  representations.  The  whole  mechanism  of 
feminine  frigidity  lies  in  this  proposition.  Sometimes  the  cause  of  this 
suppression  of  a  whole  group  of  normal  psychophysical  reactions  is 
found  at  the  very  beginning  of  the  sexual  life.  And  here  again  we 
see  the  overwhelming  effect  of  clumsy  defloration.  The  wife  gets  a  feel- 
ing of  disgust  for  the  sexual  act,  and  at  the  same  time  inhibits  all 
potential  possibilities  of  voluptuous  sensations.  Outside  even  of  such 
conditions  where  there  is  a  physical  starting-point,  there  may  be  reasons 
of  a  moral  nature.  Perhaps  she  does  not  care  enough  for  her  husband, 
or  has  married  him  under  protest,  etc.  At  other  times,  and  we  have 
seen  many  examples  of  this,  it  is  incomplete  coitus  practised  from  the 
start,  either  in  marriage  or  in  a  less  settled  union,  which  is  the  cause 
of  it.  Then  for  one  reason  or  another  the  relations  become  normal, 
but  the  frigidity  persists. 

Sometimes,  finally,  religious  ideas  are  the  cause  of  this,  and  there 
are  women  who,  by  virtue  of  their  education,  consider  it  shameful  and 
degrading  to  entertain  any  sensual  interpretations  of  the  genital  life. 

Here  is  the  case  of  a  woman,  the  mother  of  six  children,  who  is 
incapable  of  any  voluptuous  sensation.  This  is  because  at  seven  or 
eight  years  of  age  she  handled  herself.  Her  parents  caught  her  at  it 
and  punished  her  severely.  She  was  taught  to  abhor  everything  con- 
nected with  her  organs  as  shameful  and  wrong.  When  she  was  married, 
she  submitted  to  her  husband's  approaches  but  would  never  permit  her- 
self to  have  any  feeling.  As  the  years  passed  she  became  gradually 
exhausted  by  these  constant  struggles  against  what  she  considered  as 


MANIFESTATIONS  OF  A  GENITAL  NATURE.  77 

immoral,  and  she  succumbed  to  a  very  severe  attack  of  neurasthenia  at 
the  age  of  thirty-three.  When  cured  and  equipped  with  more  sensible 
ideas,  after  several  months'  isolation  and  psychotherapy,  she  still  went 
two  years — so  strong  had  been  her  previous  inhibition — without  experi- 
encing any  pleasure  in  her  conjugal  relations,  although,  as  she  no 
longer  felt  any  reproach  on  the  subject,  she  greatly  desired  to  enjoy 
such  experience. 

Under  other  circumstances  it  is  the  fear  of  pregnancy,  or,  inversely, 
the  desire  of  maternity,  in  other  cases,  again,  a  too  marked  sexual 
altruism,  anxiety  that  her  companion  should  have  his  pleasure,  which 
comes  in  as  an  intervening  factor  to  inhibit  all  mental  representations 
of  a  voluptuous  nature. 

A  wholly  different  mechanism  results,  on  the  other  hand,  from  an 
excessive  desire  for  sensations  of  this  kind.  It  is  the  fear  of  not 
experiencing  them  which  engenders  frigidity. 

In  fact  the  coldness  or  lack  of  passion  maintains  itself.  In  sexual 
phenomena  all  the  psychological  mechanisms  of  expectancy,  memory, 
and  association  of  ideas  are  developed  to  an  extreme. 

In  the  absence  of  all  previous  experience  it  is  evident  that  the  rôle 
which  the  imaginative  faculties  can  play  must  be  practically  nil.  This 
explains,  moreover,  why  frigidity  is  such  a  common  phenomenon  at  the 
beginning  of  the  sexual  life.  But  if  the  woman  does  not  become 
obsessed  by  this  frigidity,  her  education  will  go  on  rapidly.  If  she  does 
become  obsessed,  or  if  one  of  the  factors  which  we  have  described  above 
should  inter\^ene,  one  can  conceive  how  frigidity  may  sometimes  become 
definitely  established. 

There  are,  as  a  matter  of  fact,  wives  who  have  passed  their  life 
without  knowing  any  sensual  pleasure.  There  are  some  who,  being 
virtuous  women,  admit  the  fact,  accept  it  as  such,  and  pay  no  attention 
to  it.  During  the  sexual  act  they  think  of  something  else.  Some  of 
them  in  fact  experience  no  pleasure  until  after  several  years  of  marriage. 
On  the  other  hand,  there  are  those  who  think  of  nothing  else,  and  who 
go  about  looking  for  someone  who  can  **  transport  them  to  the  seventh 
heaven,"  and  it  is  frequently  for  a  reason  of  this  nature  that  one  sees 
women  leaving  their  regular  life,  taking  lovers,  and  becoming  sexual 
perverts.  One  calls  them  seekers  after  sensations.  There  is  an  error 
in  the  last  plural.  They  are  not  seeking  sensations;  they  are  seeking 
only  one.  They  are  more  to  be  pitied  than  blamed,  for  they  are  the 
prey  of  a  powerful  and  lasting  obsession,  which  undermines  their 
physical  and  moral  life. 

3.  Neurasthenic  Conddtions  of  Sexual  Origin. — Outside  of  the 
properly  so-called  genital  disturbances,  there  exist  in  women  a  very 
large  number  of  neurasthenic  conditions  which  are  of  sexual  origin,  but 
purely  psychic.  A  woman,  much  more  commonly  than  a  man,  is  apt 
to  mingle  her  sentimental  life  and  her  sexual  life.    The  phenomena  of 


78  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

the  one  react  on  the  other,  and  vice  versa.  We  shall  try  to  show  else- 
where that  sentimental  love  is  only  a  peculiar  form  of  emotionalism, 
and  that,  on  the  other  hand,  the  large  majority  of  neurasthenic  con- 
ditions have  emotional  phenomena  as  their  basis.  Everything  that  aJffects 
the  domain  of  sentiment,  or  those  spheres  which  are  more  or  less  closely 
dependent  on  it,  is,  therefore,  by  definition  susceptible  of  becoming  a 
basis  of  neurasthenic  states.  And  this  is  the  reason,  we  think,  that  we 
so  often  find,  on  questioning  these  patients,  that  the  starting-point  of 
their  troubles  has  been  in  the  sexual  life. 

These  original  troubles  are  of  various  natures.  The  rôle  of  sexual 
abstinence  is  considerable,  whether  it  is  a  question  of  women  who  are 
more  or  less  neglected  by  their  husbands,  or  of  widows,  or  of  unmarried 
women  who  are  obsessed  in  various  degrees  by  their  lack  of  sexual 
satisfaction  or  the  wrong  which  their  maternal  instinct  suffers.  All  the 
mechanisms  which  we  have  gone  over  at  the  beginning  of  this  study 
may  come  in  in  the  creation  of  intermittent  emotional  states.  To 
these  there  are  added  more  or  less  serious  neurasthenic  symptoms,  whose 
origin  one  must  know  how  to  find,  an  origin  which  is  often  more 
difficult  to  discover  because,  when  there  are  no  positive  sexual 
manifestations,  it  is  very  apt  to  be  carefully  dissimulated.  It 
often  happens  that  women  have  no  idea  themselves  of  the  cause  of 
their  condition.  There  is  thus  established,  as  it  were,  a  sort  of  com- 
promise between  the  strength  of  the  physical  sexual  life  and  the  in- 
tensity of  the  sentimental  life,  unless  the  latter  finds  material  for  its 
development  in  the  mental  make-up. 

It  is,  therefore,  quite  common  to  find  in  those  who  are  chaste  of 
necessity  these  conditions  of  excessive  sentimentality,  which  are  a  source 
of  continued  emotional  conditions,  and  which  lead  to  the  development 
of  neurasthenic  manifestations,  even  to  extreme  loss  of  weight  and 
physical  as  well  as  moral  asthenia. 

These  facts  have  an  importance  of  their  own,  for  they  show  how 
the  phenomena  of  the  physical  life  may  react  on  the  moral  condition 
of  people,  and  also  because  they  offer  explanation  for  a  great  number 
of  conditions,  which  there  is  a  very  general  tendency  to  consider  as 
crypto-genetic  and  which  are  apt  to  be  attributed  to  a  series  of  organic 
causes. 

Before  leaving  the  study  of  pseudo-sexuals,  we  wish  to  devote  a  short 
paragraph  to  the  conjugal  reactions  of  sexual  neurasthenics. 

Conjugal  neurasthenia  of  sexual  origin  is  a  very  commonly  observed 
phenomenon. 

It  sometimes  happens  that  a  husband  presenting  functional  sexual 
manifestations  holds  his  wife  responsible  and  causes  her  to  share  his 
convictions.  Under  other  circumstances  this  conviction  springs  up 
spontaneously  in  the  mind  of  the  wife,  who,  in  view  of  her  companion 's 
impotence,  imagines  that  it  must  be  on  account  of  some  anomaly  in  her 
own  constitution.     Sometimes  the  wife  is  haunted  by  the  fear  of  im- 


MANIFESTATIONS  OF  A  GENITAL  NATURE.      79 

potence  on  the  part  of  her  husband,  and  at  the  same  time,  while  she  is 
intensifying  the  source  of  his  impotence  by  letting  him  see  her  state 
of  anxiety,  she  is  inhibiting  herself  and  becomes  cold,  and  finally  ends 
by  suffering  on  her  own  account  for  her  frigidity.  The  inverse  con- 
ditions may  be  presented,  and  the  woman,  being  generally  lacking  in 
warmth  at  the  beginning  of  her  married  life,  may  by  her  coldness  cause 
her  husband  so  much  anxiety  that  he  believes  himself  to  be  at  fault. 
Hence  there  is  excitement  at  the  moment  of  sexual  approach,  with  con- 
sequent impotence.  In  this  way  are  born  those  conjugal  neurasthenias 
which  spoil  the  lives  of  married  couples,  and  which  become  the  starting- 
point  of  physical  and  moral  depressions  which  are  often  extremely  per- 
sistent, because  rational  therapy  has  not  been  applied  to  them  or  has 
not  been  called  forth  by  confidences.  Such  patients,  in  fact,  seem  to 
have  a  peculiar  feeling  of  shame  in  speaking  to  a  physician  about  any 
such  experiences.  And  we  have  seen  people  living  together  for  ten  or 
twenty  years  most  unhappily,  but  always  refusing  to  confess  the  true 
cause  of  the  troubles  which  were  disturbing  them. 

C.  False  Gynaecological  Manifestations. — Apropos  of  this  category 
of  troubles  we  might  repeat  almost  word  for  word  what  we  have  just 
said  on  the  subject  of  false  gastropathies.  These  are  essentially  progres- 
sive neuropathic  disturbances  created  by  medical  suggestion.  A  slight 
leucorrhœa,  an  excessive  or  too  long-continued  flow  at  the  menstrual 
period,  if  treated  by  local  therapeutic  measures,  is  often  the  beginning 
of  weeks,  months,  sometimes  years,  of  special  treatment,  during  the 
course  of  which  time  there  will  be  established  by  degrees  all  the  sub- 
jective phenomena  which  the  questions  of  the  specialist  have  indicated, — 
heaviness  of  the  lower  abdomen,  pains  in  the  kidneys,  rapid  fatigue  in 
walking  or  in  standing.  Other  phenomena  may  become  associated  with 
the  region  of  the  urinary  tracts  or  the  digestive  apparatus.  The  woman 
who  is  a  false  uterine  will  develop,  by  the  gradual  growth  of  suggested 
ideas,   a  false  gastropathy  or  a  false  urinosis. 

The  starting-points  of  these  various  manifestations,  however,  are 
variable.  Sometimes  they  are  the  slight  quasi-physiological  disturb- 
ances that  we  have  already  described.  Sometimes  it  is  a  woman's  great 
anxiety  for  maternity  which  has  led  her  to  consult  a  gynaecologist. 
Sometimes,  again,  it  is  the  sexual  manifestation  which  we  have  just 
studied  which  forms  the  starting-point  of  errors  of  interpretation,  and 
turns  the  woman's  mind  toward  the  idea  of  some  real  affection  of  her 
genital  apparatus. 

And  then  the  physician  comes  in,  who  often,  instead  of  trying  to 
turn  the  patient's  attention  away  from  her  genital  organs,  believes  it 
to  be  his  right  and  duty  to  **try  to  do  something."  He  inserts  tampons, 
he  draws  up  a  special  hygiene  for  her,  and  practises  dilatations,  when 
he  does  not  resort  to  gynaecological  massage,  which,  of  all  special  thera- 


80  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

peutics,  is  the  one  which  is  most  apt  to  fix  the  patient's  mind  upon  her 
genital  regions. 

We  have  happened  to  see  a  great  number  of  women  whose  existence 
was  absolutely  centred  on  the  idea  of  a  metritis  whose  very  existence 
was,  to  say  the  least,  doubtful.  In  this  way  false  utérines  are  started, 
and  in  this  way  are  also  set  up  pseudo-salpingitis  and  pseudo-ovaritis, 
because  women  who,  after  various  suggestions,  have  felt  more  or  less 
vague  pains  in  those  regions,  have  consulted  physicians  who  have  treated 
them  for  affections  which  they  did  not  have. 

And  though  the  local  phenomenon  in  itself  may  not  be  of  much 
importance,  its  consequences  may  be  extreme,  by  reason  of  the  moral 
and  material  anxieties  occasioned  by  the  expense  or  the  period  of 
enforced  rest,  or  the  obsessions  to  which  such  treatment  may  lead.  Very 
serious  and  intense  neurasthenic  states  may  follow,  whose  starting-point 
lies  wholly  in  error  of  interpretation  on  the  part  of  the  patient,  and 
also,  we  must  add,  on  the  part  of  the  physician  as  well. 

There  is  -one  more  class  for  us  to  examine.  It  is  of  nervous  preg- 
nancy that  I  wish  to  speak.  Here  it  is  not  usually  a  question  of  outside 
origin,  but  of  self-suggestion.  There  are  some  women  who  are  haunted 
by  the  idea  of  maternity,  because  they  either  so  greatly  desire  it  or  fear 
it.  We  then  find  developing  in  them  a  curious  group  of  phenomena 
which  simulate  pregnancy,  with  the  exception  of  uterine  gravidity, 
even  to  its  very  last  symptom.  Suppression  of  the  menses,  or  at  least 
some  irregularity,  progressive  enlargement  of  the  abdomen,  modifications 
of  the  breasts,  and  the  so-called  sympathetic  disturbances,  such  as  flush- 
ings, vomiting,  etc.,  mark  its  stages. 

Localized  abdominal  tympanism  may  be  partially  explained  by  more 
or  less  conscious  modifications  of  the  muscular  tonicity  of  the  walls 
— in  their  contractions  and  relaxings.  If,  on  one  hand,  the  sympa- 
thetic disturbances  may  unquestionably  be  of  a  suggestive  nature,  how 
can  one  conceive  of  suggestion  as  having  any  influence  on  amenorrhœa 
or  modifications  of  the  breasts  ?  Is  one  not  led  to  concede  that  organic 
modifications  may  be  directly  produced  under  the  influence  of  a  per- 
sistent mental  representation  ? 

In  short,  the  signs  of  pregnancy,  outside  of  the  properly  so-called 
physical  signs,  are  sometimes  so  marked  that  they  deceive  even  a 
physician.  Certain  cases  have  occurred  in  which  a  diagnosis  could 
only  be  made  by  the  prolongation  of  the  signs  far  beyond  the  normal 
limits  of  gestation.  But  sometimes  a  false  nervous  pregnancy  may  be 
followed  by  false  labor,  the  woman  feeling  all  the  pains,  and  parturition 
alone  being  lacking. 

These  observations  on  nervous  pregnancy  lead  us  to  the  study  of 
a  last  phenomenon.  We  know  that  emotion  may  stop  or  suppress  the 
courses.  Therefore,  may  we  not  question  whether  amenorrhœa  may,  or 
may  not,  be  a  neuropathic  manifestation  ?  That  it  exists  in  a  great  many 
nervous  conditions,   in  the   course   of  mental  anorexias  and   certain 


MANIFESTATIONS  OF  A  GENITAL  NATURE.  81 

melancholic  states,  as  well  as  in  hysterics  and  even  neurasthenics,  is  a 
fact  of  common  observation  of  which  there  is  no  doubt.  But  how  may- 
it  be  interpreted?  It  seems  to  us  very  certain  that  in  a  large  number 
of  cases  amenorrhœa  is  a  result  not  of  a  neuropathic  condition,  but  of 
a  more  or  less  marked  cachectic  state  which  has  been  brought  about  by 
insufficient  food  as  a  result  of  a  primary  neuropathic  condition.  More- 
over, we  see  neuropathic  conditions  as  a  secondary  development  in 
chlorotic,  anaemic,  tuberculous,  and  genital  patients  in  whom  the  sup- 
pression of  the  courses  is  a  common  phenomenon. 

Outside  of  those  cases  of  nervous  pregnancy  where  amenorrhœa  is  a 
positive  fact,  and  apparently  of  nervous  origin,  though  rarely  absolute, 
the  question  whether  amenorrhœa  may  be  considered  as  a  neuropathic 
phenomenon  still  remains  to  be  solved. 


CHAPTER  IV. 

FUNCTIONAL  MANIFESTATIONS  IN  THE  RESPIRATORY  APPARATUS. 

Neuropathic  disturbances  of  the  respiratory  apparatus  are  evidently 
much  less  common  than  those  which  occur  in  the  digestive  or  genito- 
urinary apparatus.    They  are,  however,  rather  frequently  observed. 

We  shall  study  successively  nasal  and  laryngeal  difficulties,  then  the 
respiratory  troubles  properly  so  called. 

Nasal  troubles  are  of  diverse  origins.  Often  in  this  case  medical 
suggestion  has  come  in.  The  patients  really  have  a  slight  organic 
swelling,  a  slight  congestion  of  the  mucous  membrane,  an  abnormal 
turbinated  bone, — troubles  which  have  no  very  great  significance  and 
which  can  be  and  should  be  treated  in  subjects  who  are  not  impres- 
sionable. If,  on  the  other  hand,  one  treats  a  neuropath  in  these  con- 
ditions, far  from  improving  him  one  will  generally  manage  to  fix  in 
his  mind  the  idea  of  a  nasal  affection,  around  which  his  psychism  will 
become  centred.    Numerous  troubles  may  then  be  set  going. 

The  action  of  the  ideas  on  the  mucous  secretion  is  a  very  common 
phenomenon.  When  has  one  greater  need  of  a  handkerchief  than  when 
one  has  forgotten  it?  In  the  same  way  we  have  seen  nervous  people 
imbued  with  the  conviction  that  they  have  a  nasal  lesion,  always  going 
about  with  a  handkerchief  in  their  hands  and  using  it  twenty  to  fifty 
times  an  hour.  Sometimes  the  mental  representation  leads  to  a  repeated 
or  constant  snuffling.  In  this  way  there  may  be  developed  regular 
tics  of  nasal  origin.  Sometimes,  again,  the  thing  becomes  complicated, 
and  the  patient,  persuaded  that  he  can  no  longer  breathe  through  his 
nose,  experiences  a  very  marked  inconvenience  in  his  respiration,  on 
which  his  attention  afterwards  becomes  fixed. 

Here,  as  in  all  other  functional  localizations,  very  serious  neuras- 
thenic conditions  may  follow  by  the  usual  mechanisms, — material 
anxiety,  as  a  result  of  medical  expenses,  loss  of  interest  in  one's  work, 
by  reason  of  dissipated  attention,  etc.  Although  such  cases  are  rather 
rare,  we  have  nevertheless  seen  them. 

Laryngeal  disturbances  are  perhaps  more  frequent  than  those  of 
nasal  localization.  We  shall  not  take  up  here  the  subject  of  hysterical 
mutism,  a  complex  manifestation  which  we  shall  meet  elsewhere.  We 
have  before  us  tjiree  categories  of  patients  :  some  are  laryngeal  phobias, 
others  are  attacked  in  varying  degrees  by  aphonia,  while  still  others 
present  spasmodic  phenomena. 

Neuropathic  manifestations,   caused  by  the  simple  fixation  of  the 

psychism  of  the  subjects  on  their  larynx,  are  comparatively  frequent, 

as  may  readily  be  explained  by  the  multiplicity  of  functions  which 

require  the  use  of  a  good  voice,   as  in  the  case  of  singers,   actors, 

82 


MANIFESTATIONS  IN  THE  RESPIRATORY  APPARATUS.    83 

advocates,  orators,  and  street  criers  of  every  kind.  Let  any  slight 
laryngeal  trouble  which  may  happen  accidentally  last  more  than  a 
day,  or  let  even  the  unfounded  idea  of  a  possible  laryngeal  trouble 
disturb  the  patient's  mind,  and  fixation  may  be  produced. 

Sometimes  these  patients  go  to  consult  specialists,  who  conscientiously 
assure  them  that  there  is  nothing  wrong;  they  go  to  see  others,  until 
at  last  they  find  a  specialist  who,  perchance  weary  of  arguing,  will 
consent  to  treat  them  locally.  The  patients  will  henceforward  and  for 
a  long  time  have  false  laryngitis.  These  are  the  ^patients  whom  one 
sees  taking  infinite  care  of  themselves,  swathing  their  throats  in  silk 
handkerchiefs,  and  sucking  all  the  pastilles  which  are  advertised  in  the 
daily  press.  A  draft  of  air  worries  them;  a  change  of  temperature 
terrifies  them. 

Sometimes  the  phenomena  do  not  remain  purely  psychic,  and  the 
situation  is  comphcated.  Such  patients  try  their  voices  all  day;  they 
cough  to  clear  their  throats;  thus  a  cough  of  purely  nervous  origin 
may  be  started,  which  though  voluntary  at  first  will  a  little  later  become 
purely  automatic. 

Things  may  go  still  further,  and  these  same  patients,  by  simple 
mental  representation,  however  slightly  they  may  respond  to  auto-  or 
hetero-suggestion,  may  nevertheless  develop  more  or  less  marked 
phenomena  of  aphonia  or  hoarseness. 

Sometimes  there  is  simple  diminution  of  the  volume  of  the  voice, 
the  patient  hardly  dares  to  speak,  he  whispers  rather  than  speaks  ;  some- 
times there  is  hoarseness  which  is  probably  due  to  the  muscular 
asynergias  which  the  mental  representation  can  create.  Does  not  one 
often  find,  on  the  other  hand,  that  under  the  stress  of  emotion  the 
voice  breaks  and  its  tone  is  changed?  This  is  what  might  be  called  a 
phantom  voice. 

These  are  the  same  symptoms  that  continued  laryngeal  preoccupa- 
tion is  liable  to  bring  about.  Here,  as  we  have  already  shown  else- 
where and  as  we  shall  continue  to  indicate  many  times  again,  when 
phenomena  of  preoccupation  (or  obsessions,  if  one  prefers  so  to  call 
them)  become  localized  on  an  organ,  there  will  finally  be  established 
in  this  organ  the  same  symptoms  which  are  apt  to  be  suddenly  or 
directly  produced  by  aii  emotional  shock. 

Spasm  of  the  vocal  cord  may  also  be  met  with  in  neuropaths.  We 
have  seen  a  case  of  this  kind  in  the  service  of  one  of  us,  an  old  hysterical 
patient  who  was  very  peculiar  and  who  had  been  examined  by  all  the 
specialists  without  any  one  of  them  being  able  to  attribute  the 
phenomenon  which  she  presented  to  any  affected  organ.  It  was  a  case 
of  laryngeal  spasm  which  occurred  in  a  peculiarly  intense  degree  when 
the  patient  was  lying  down,  but  which  would  continue  when  she  was 
seated  or  standing,  although  it  was  then  much  less  marked.  It  was 
accompanied  by  sounds  of  snorting  and  deep  breathing.  The  snorting 
disappeared  completely  during  sleep.    The  spasm  had  made  its  appear- 


84  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

ance  after  a  violent  emotion,  and,  once  established,  had  at  first  been 
intermittent,  but  afterwards  became  permanent.  Repeated  examinations 
of  the  larynx  showed  a  wide  glottis,  normal  vocal  cords,  functioning 
easily  and  without  paralysis  or  spasm.  From  the  fact  of  her  con- 
tinued good  state  of  health,  the  absence  of  cyanosis,  and  the  total  disap- 
pearance of  the  phenomena  during  sleep,  and  of  their  diminution  during 
wakeful  times  in  the  night,  and  when  the  patient  did  not  think  that  she 
was  observed,  and,  finally,  on  account  of  the  past  neuropathic  history 
of  the  patient,  a  diagnosis  was  made  of  hysterical  functional  spasm 
of  the  constrictor  muscles.  This  diagnosis  was  further  confirmed  by 
the  fact  that  on  pretending  to  eatheterize  the  larynx  the  spasm  would 
disappear.  This  patient,  who  was  under  the  observation  of  one  of  us 
for  ten  years,  and  in  whom  the  affection  dated  back  for  fifteen  years, 
has  always  been  in  the  same  condition. 

Such  intense  manifestations  are  rare  ;  but  cases  less  marked,  or  only 
recurring  at  intervals,  are  frequently  seen.  These  cases  often  have  a 
particular  genesis.  Swallowing  the  wrong  way  has  been  known  to 
give  rise  to  them.  A  subject,  having  by  a  false  attempt  at  swallowing 
introduced  a  little  liquid  or  some  solid  particle  into  his  respiratory 
tubes,  is  seized  at  the  moment  with  a  legitimate  spasm.  But  after  that 
he  will  live  in  dread,  almost  in  expectancy,  of  this  spasm,  which  may 
be  produced  by  the  slightest  disturbance  of  deglutition,  or  even,  with- 
out any  trouble  of  that  kind,  by  a  simple  mental  representation,  or  on 
the  occasion  of  any  emotion,  whether  trifling  or  profound. 

The  respiratory  troubles  of  neuropaths,  properly  so  called,  are  ex- 
tremely interesting  to  study,  because  they  have  a  sufficiently  distinct 
objectivity  to  enable  one  to  detect  them  easily  and  analyze  them,  and 
to  separate  the  different  mechanisms  which  are  liable  to  produce  them. 
Here  again  we  find  ourselves  in  the  presence  of  two  classes  of  patients. 
The  one  comes  under  the  head  of  phobies  of  diseases  of  the  respiratory 
tracts.  "We  shall  take  them  up  immediately.  The  others  present  effective 
functional  disturbances. 

Diminution  of  respiratory  interchange  is  a  common  factor  which  is 
present  in  nearly  all  neuropaths  when  in  a  state  of  preoccupation  or 
obsession.  It  is  merely  a  normal  phenomenon  of  which  the  continuity 
is  abnormal.  All  phenomena  of  attention,  expectation,  or  preoccupa- 
tion, even  in  the  most  healthy  individual,  are  accompanied  by  a  diminu- 
tion of  the  number  and  the  depth  of  respirations.  Watch  a  brain 
worker  seeking  for  a  solution  of  some  difficult  problem,  watch  a  work- 
man while  performing  some  delicate  and  careful  piece  of  work,  look  at 
a  spiritually  minded  devotee  while  praying  in  church,  notice  the  attitude 
of  the  listeners  to  an  exciting  story,  and  you  will  be  able  to  verify 
the  fact  that  in  all  these  individuals  their  respiration  is  less  frequent  and 
less  profound,  and  that,  even  without  experiencing  any  emotional 
phenomena,  they  are  obliged  from  time  to  time  to  draw  a  deep  breath, 
on  account  of  the  organic  need  created  by  the  insufficiency  and  in- 


MANIFESTATIONS  IN  THE  RESPIRATORY  APPARATUS.    85 

frequency  of  their  inspirations  and  respirations  during  the  period  of 
attention. 

Now,  the  nervous  man  while  experiencing  any  symptoms  is,  as  a 
matter  of  fact,  in  a  state  of  continued  attention,  observation,  expecta- 
tion, and  preoccupation,  and  he  holds  his  thorax  comparatively  immov- 
able, at  least  to  such  an  extent  that  after  a  certain  time  he  gets  the 
habit  of  not  breathing  deeply  enough. 

We  have  systematically  examined  by  means  of  a  spirometer  the 
volume  of  air  expired  by  a  great  number  of  neuropaths  afflicted  with  the 
most  various  symptoms.  We^have  thus  been  able  to  ascertain  the  fact 
that  all  these  patients  show  a  diminution,  which  is  sometimes  consider- 
able, in  their  vital  capacity  and  in  the  amount  of  air  they  inhale. 

As  to  the  amount  of  respiratory  interchange,  we  have  obtained 
three  hundred,  two  hundred,  and  even  one  hundred  cubic  centimetres, 
instead  of  the  normal  five  hundred.  As  to  the  vital  capacity,  it  rarely 
passes  three  litres,  and  the  usual  amounts  vary  between  a  litre  and  a 
half  and  two  litres  and  a  half  in  individuals  who  are  otherwise  normally 
constituted.  We  naturally  in  the  course  of  examinations  have  guarded 
against  any  possibility  of  suggestion,  contenting  ourselves  with  merely 
showing  the  patient  how  the  apparatus  works,  without  telling  him  the 
object  of  our  search  and  its  probable  result.  In  order  that  the  patient 
shall  have  no  knowledge  of  the  results  obtained,  we  always  cover  the 
dial  of  the  apparatus  on  our  first  examination. 

Here  then  we  have  established  the  first  objective  fact,  and  one  which 
is  fertile  in  consequences.  On  the  one  hand,  it  explains  the  rapidity 
of  breathing  while  the  patient  is  walking,  speaking,  or  even  standing 
still.  On  the  other  hand,  it  is  quite  certain  that  the  insufficiency  of 
respiratory  interchange  as  a  phenomenon  of  nervous  origin  may  have 
consequences  from  the  point  of  view  of  bodily  reactions.  And  we 
should  not  be  at  all  surprised  if  a  certain  number  of  the  urinary 
modifications  which  have  been  pointed  out  in  nervous  patients  might 
be  attributed  to  phenomena  of  this  kind,  or  the  inverse,  which  may 
also  be  observed  under  special  circumstances. 

This  very  diminution  of  respiration  may  constitute  an  autonomous 
neuropathic  manifestation,  of  which  we  have  seen  a  very  curious 
example. 

Madame  X.,  forty-two  years  of  age  and  the  mother  of  six  children, 
was  afflicted  with  a  very  peculiar  respiratory  trouble.  At  different 
times  on  one  of  her  good  days,  and  three  or  four  times  a  minute  on 
a  bad  day,  the  patient  would  draw  long  deep  breaths  exactly  like  what 
we  commonly  call  a  sigh  of  relief.  The  trouble  went  on  for  two  years. 
It  would  appear  coincident  with  all  kinds  of  preoccupations.  It  was 
intensified  by  excitement.  The  fact  of  going  to  dine  in  town,  or  of 
receiving  friends,  etc.,  would  make  it  considerably  worse.  Moreover, 
the  patient  noticed  that  several  days  before  the   appearance  of  her 


86  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

courses  it  increased  spontaneously.  In  addition  to  this  very  peculiar 
phenomenon  the  patient  showed  signs  of  very  marked  astasia-abasia. 

In  examining  the  patient  attentively  when  the  phenomenon  occurred, 
— and  we  might  as  well  state  at  once  that  all  that  was  necessary  was 
to  look  for  it  and  it  would  occur, — this  is  what  one  would  find.  The 
patient  remained  in  an  almost  absolute  state  of  apnœa  for  a  certain 
number  of  seconds.  We  have  counted  these  respiratory  pauses  with  a 
stop-watch,  and  have  found  them  to  last  from  twenty  to  thirty  seconds. 
The  pause  terminated  by  a  long  involuntary  inspiration.  It  is  evident 
that  this  long  inspiration  was  directly  dependent  upon  the  apnœa  ;  and 
when  ordering  the  patient  to  breathe  in  a  regular  manner,  at  the  rate 
of  ten  deep  breaths  in  a  minute,  the  phenomenon  would  not  be  repeated. 
The  intensity  and  frequency  of  these  deep  breaths  were  in  direct  pro- 
portion to  the  attention  which  the  patient  brought  to  bear  upon  the 
phenomenon  or  the  state  of  expectancy  that  she  was  in  concerning  it. 
Thus,  fearing  that  it  would  occur  while  she  was  busy  about  her  daily 
occupations,  she  always  had  with  her  an  effective  reason  for  producing  it. 

This  patient  had  narrowed  her  life  down  to  such  an  extent  that  she 
would  no  longer  leave  her  home,  and  as  a  matter  of  course  the  neuro- 
pathic symptoms  from  which  she  was  suffering,  having  become  a  veritable 
obsession,  grew  steadily  worse. 

Here,  then,  we  have  a  first  series  of  disturbances  in  which  the 
mechanism  of  the  attention  is  concerned  as  well  as  a  more  or  less 
obsessive  preoccupation,  which  disturbances  may  become  singularly 
complicated  when  the  attention  is  fastened  on  the  respiratory  tracts 
themselves. 

Emotion  very  frequently  has  a  strong  effect  upon  the  respirations, 
and  under  two  different  forms.  Sometimes  it  has  what  we  might 
describe  as  a  sudden  switching  off  of  the  respiratory  function,  which  is 
cut  short.  The  patients  complain  of  their  throats  being  contracted,  they 
suffer  from  a  sense  of  emotional  restriction  or  oppression,  and  cannot 
breathe.  When  the  emotion  occurs  again,  it  brings  on  the  same 
phenomena,  which  may  under  certain  circumstances  have  such  an 
effect  as  to  cause  that  diminution  of  respiratory  interchange  of  which 
we  were  just  speaking. 

The  usual  effect  of  emotion  in  causing  symptoms  in  the  respiratory 
functions  acts  in  quite  the  opposite  way.  A  nervous  pseudo-asthma 
forms  the  type  of  what  we  might  call  respiratory  emotionalism. 

Here  are  two  examples  which  will  help  us  more  clearly  to  under- 
stand the  genesis  of  this  difficulty. 

Mr.  X.,  aged  thirty-eight,  had  a  small  business  in  Paris.  He 
wakened  once  in  the  middle  of  the  night,  thinking  he  heard  a  noise  in 
his  shop;  he  felt  uneasy,  and  became  quite  disturbed,  and  then  was 
taken  with  an  intense  polypnœa.  He  gasped  for  air,  and  was  obliged 
to  run  to  his  window  to  get  relief.  This  phenomenon  lasted  for  several 
hours,  then  finally  he  gradually  grew  calm,  but  he  could  not  go  to 


MANIFESTATIONS  IN  THE  RESPIRATORY  APPARATUS.    87 

sleep  again  that  night.  The  next  night  he  wakened  again,  this  time 
without  any  cause  of  anxiety,  but  the  same  symptoms  occurred.  How- 
ever, the  duration  of  the  attack  was  perhaps  not  quite  so  long.  He  went 
back  to  bed,  and  was  able  to  get  to  sleep,  but  he  awakened  a  second  time 
and  was  seized  with  a  second  attack.  In  the  weeks  that  followed  this 
affection  persisted,  and  our  patient  would  be  taken  from  one  to  four 
times  in  a  night  with  symptoms  of  this  nature.  His  attacks  never  came 
on  in  the  daytime;  so  he  never  had  a  chance  to  let  us  see  him  in  one 
of  them,  and  we  could  not  tell  whether  the  period  of  polypnœa  was 
preceded  or  not  by  a  period  of  apnœa.  According  to  the  patient's 
description,  it  would  seem  that  there  was  none,  and  that  the  polypnœa 
was  produced  at  the  moment  of  wakening. 

What  mechanism  was  brought  into  play  in  this  particular  ease?  It 
seems  certain  to  us  that  the  first  attack  had  been  brought  about  solely 
by  anxiety  and  excitement.  As  to  the  following  attacks,  it  was  the 
memory  of  the  previous  manifestation  which  created  them.  As  soon  as 
the  patient  was  reassured  concerning  his  condition,  he  ceased  to  have 
any  of  these  symptoms. 

Another  case,  quite  resembling  this,  was  presented  by  a  patient  thirty 
years  of  age,  a  printer  and  political  writer,  very  much  interested  in 
questions  of  the  day,  and  who  in  the  midst  of  an  election  campaign  was 
suddenly  awakened  in  the  night.  He  thought  he  was  called  to  his 
printing-office,  and  leaped  suddenly  out  of  bed,  and  was  seized  with 
an  attack  of  oppression  with  polypnœa,  which  lasted  about  two  hours, 
but  finally  passed  off.  The  same  phenomena  reappeared  on  the  follow- 
ing days,  and  when  we  saw  the  patient  he  had  been  suffering  in  this 
way  for  three  months.  In  his  case  also  we  were  not  able  to  determine 
whether  a  period  of  apnœa  occurred  before  the  period  of  polypnœa. 

It  is  unnecessary  to  add  that  these  two  patients  believed  that  there 
was  something  very  serious  the  matter  with  them,  and  that  they  were 
obsessed  about  their  affection.  They  were  convinced  that  they  had 
uraemic  and  cardiac  symptoms,  or  at  least  that  they  were  asthmatic. 
Nevertheless,  in  each  case  their  cure  was  only  a  matter  of  several  days. 

As  to  the  pathological  physiology  of  such  symptoms,  we  possess  no 
positive  explanation  in  the  absence  of  exact  information  concerning  the 
way  they  act  at  the  start.  Are  they  patients  who,  under  the  influence 
of  some  emotion,  have  a  period  of  ''shortness  of  breath,"  with  apnœa 
and  a  sensation  of  suffocation,  followed  by  a  period  of  a  sort  of  com- 
pensatory polypnœa?  Or,  rather,  is  it  not  emotion  which  has  been  the 
immediate  means  of  making  them  pant?  The  two  explanations  are 
equally  plausible.  It  is  possible  also  that  both  mechanisms  may  be 
combined  in  the  same  subject. 

Such  manifestations  are  comparatively  easy  to  diagnose.  In  the 
absence  of  any  cardiac  or  renal  symptoms,  one  cannot  help  but  think  of 
true  asthma.  Such  attacks,  however,  differ  considerably  from  it,  first 
by  the  absence  of  all  secretory  phenomena,  and  further  by  the  very 


88  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

nature  of  the  respiratory  sjnnptoms.  If  there  are  phenomena  of  op- 
pression or  anguish,  these  manifestations  are  accompanied  by  a  polypnœa, 
and  not  a  dyspnœa  that  is  markedly  expiratory  as  in  asthma. 

A  third  type  of  functional  respiratory  disturbances  consists  of 
a  more  or  less  extensive  immobilization  of  the  thorax. 

Miss  X.,  thirty-three  years  of  age,  was  brought  to  us  one  day,  as 
a  general  medical  patient,  to  confirm  a  diagnosis  of  incipient  pulmonary 
tuberculosis. 

On  examination,  it  was  found  that,  as  a  fact,  the  vesicular  murmur 
of  the  right  apex  was  extremely  diminished  and  almost  absent.  Per- 
cussion and  auscultation  while  speaking  or  coughing,  nevertheless,  gave 
exactly  the  same  results  on  both  sides.  On  the  second  examination, 
which  was  a  little  more  thorough,  it  was  found  that  the  diminution  of 
the  vesicular  murmur  was  not  confined  to  the  apex  only,  but  extended 
through  the  whole  length  of  the  right  lung. 

Now,  this  patient  had  never  had  a  pleurisy  or  any  respiratory 
affection  of  the  lung  whatever.  What,  then,  could  be  the  matter  with 
her?  In  inquiring  still  further  into  the  history  of  her  disease,  we 
learned  that,  six  months  before,  she  had  had  an  extremely  painful 
right  scapulo-humeral  arthritis.  The  respiratory  movements  had  ex- 
aggerated the  painful  symptoms,  and  under  these  conditions  the  patient, 
in  dread  of  the  pain,  had  in  a  purely  reflex  way  immobilized  her  right 
side.  The  pains  had  disappeared,  but  immobilization  had  remained. 
The  habit  was  formed.  As  a  matter  of  fact,  the  measurements  showed 
less  expansion  of  the  thorax  on  the  right  side  than  on  the  left  during 
the  movements  made  by  inspiration. 

We  have  had  the  opportunity  of  seeing  similar  phenomena  follow- 
ing a  stitch  in  the  side,  an  intercostal  neuralgia,  an  eruption  of 
shingles,  or  fractures  of  the  ribs.  Their  origin  is  sometimes  organic. 
Their  persistence — ^which  is  indefinite,  after  therapeutic  measures  have 
succeeded  in  fixing  the  ideas  in  the  patient's  mind,  and  that  long  after 
the  initial  pain  has  disappeared — constitutes  a  neuropathic  phenomenon, 
a  more  or  less  conscious  phobic  manifestation,  through  fear  of  a  pain 
which  no  longer  exists. 

Finally,  belonging  to  this  same  group,  there  is  a  functional  trouble 
which  is  rather  difficult  to  interpret.  We  mean  that  sensation  of  con- 
tinued oppression  of  which  certain  neuropaths  complain.  It  must  be 
clearly  understood  that  in  this  case  we  are  not  speaking  of  respiratory 
manifestations  in  the  true  sense  of  the  word,  but  rather  a  cœnaesthetie 
phenomenon.  As  a  matter  of  fact,  this  sensation  of  oppression  is  what 
goes  to  make  up  in  part  the  feeling  of  anguish  that  melancholies  ex- 
perience. It  is  no  less  true  that  it  is  quite  frequently  experienced  by 
simple  neurasthenics.  Bearing  in  mind  what  we  said  at  the  commence- 
ment of  this  study  concerning  the  diminution  of  respiratory  exchange 
in  nearly  all  neuropaths,  it  may  be  that  in  it  we  shall  find  a  mixed 


MANIFESTATIONS  IN  THE  RESPIRATORY  APPARATUS.    89 

cause — an  organic  cause   of  neuropathic  origin — of  this  sensation  to 
which  nervous  people  so  often  refer  in  telling  their  story. 

We  are  speaking  now  only  of  a  more  or  less  continuous  sense  of 
oppression.  Under  the  heading  of  transient  phenomena,  we  have  already 
seen  that  it  plays  an  integral  part  in  manifestations  of  emotional 
shock,  and  it  may  still  be  here  again  a  question  of  cœnaesthetie  phenom- 
enon, or  it  may  be  caused  by  shortness  of  breath  arising  from  some 
emotional  disturbance. 

To  conclude,  the  study  of  these  respiratory  manifestations  has 
enabled  us  to  isolate  three  mechanisms.  One  is  'due  to  attention,  a 
second  is  created  by  emotional  states,  and  a  third  is  formed  in  some 
way  by  the  crystallization  of  bad  habits.  It  has  seemed  to  us  that  the 
troubles  due  to  this  last  mechanism  deserve  to  be  included  in  the  class 
of  neuropathic  manifestations.  As  a  matter  of  fact,  although  the 
vicious  attitude  is  in  a  general  way  an  organic  phenomenon,  its  in- 
definite persistence  without  any  corresponding  persistent  organic  change 
is  seen  only  in  neuropaths. 

This  threefold  origin  of  symptoms,  which  the  study  of  respiratory 
manifestations  has  permitted  us  to  set  forth,  offers  a  general  scheme  for 
the  interpretation  of  all  functional  symptoms.  This  is  a  question  that 
we  shall  take  up  further  on,  but  which  we  ought  to  indicate  in  passing. 

We  are  now  ready  to  take  up  the  study  of  the  phobic  manifestations 
which  have  fastened  upon  the  respiratory  apparatus  and  their  con- 
sequences. 

Affections  of  the  respiratory  apparatus,  and  particularly  pulmonary 
tuberculosis,  are  so  frequent  that  there  is  nothing  astonishing  in  the 
fact  that  psychic  fixation  should  be  located  upon  the  lungs.  What,  on 
the  contrary,  is  curious,  is  to  see  that  they  are,  as  a  fact,  comparatively 
few  in  number.  False  gastropaths,  false  urinaries,  and  false  cardiacs  r 
are  much  more  commonly  met  with  than  false  pulmonaries.  This  is 
undoubtedly  due  to  the  fact  that  the  imagination,  except  in  character- 
istic hypochondriacal  tendencies,  is  not  apt  to  choose  willingly  suchj 
affections  as  are  considered  immediately  dangerous.  Neuropaths  and 
patients  with  false  organic  diseases  generally  give  them  a  wide  margin, 
and,  just  the  contrary  to  the  case  of  hypochondriacs,  they  are  not 
inclined  to  cultivate  those  affections  which  are  looked  upon  as  mortal. 

Nevertheless,  this  group  of  false  pulmonaries  does  exist;  and  the 
psychic  genesis  of  their  trouble  is  complex.  Sometimes  it  occurs  in 
individuals  with  tuberculous  heredity.  They  have  lost  a  father,  a 
mother,  a  brother,  or  sometimes  a  child  with  pulmonary  tuberculosis, 
and  thus  the  idea  of  a  possible  or  probable  heredity  haunts  the  patient, 
and  becomes  a  starting-point  of  his  psychic  fixation. 

Sometimes  it  is  the  fear  of  a  possible  contagion  which  gives  rise  to 
the  orientation.  There  are  innumerable  examples  of  medical  students, 
and  even  physicians,  who  at  some  time  in  their  lives  have  believed  them- 
selves to  be  tuberculous,  without  having  any  real  symptomatology. 


90     STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

Any  real  respiratory  infection,  such  as  the  grippe,  tracheitis,  bron- 
chitis, or  a  stitch  in  the  side,  is  sometimes  all  that  is  necessary  for 
patients  to  live  for  years  under  the  impression  that  they  are  tuberculous. 

Here  again  the  physician  is  really  often  responsible  for  such  an 
idea,  which  he  has  helped  to  fix  by  a  too  minute  auscultation  or  too 
particular  inquiry.  How  many  people  there  are  of  this  kind  who 
have  been  worried  by  the  persistent  idea  of  the  possibility  of  a  latent 
tuberculosis,  because  they  have  been  asked  whether  they  have  never  spit 
blood,  or  whether  they  have  never  had  a  continual  cough,  or  if  there  has 
never  been  any  tuberculosis  in  their  family. 

But  tuberculosis  is  not  always  the  only  subject  for  fear.  Some- 
times it  may  be  asthma,  sometimes  emphysema,  and  sometimes  chronic 
bronchitis.  We  have  seen  patients  laboring  under  the  false  impression 
that  they  had  pleural  adhesions. 

Once  the  psychic  orientation  is  made,  what  phenomena  may  develop 
from  them? 

Of  them  all,  a  cough  is  by  all  means  the  most  frequent.  Haunted 
by  the  idea  of  a  possible  affection  of  the  lung,  the  patients  force  them- 
selves to  cough  to  see  whether  there  may  not  be  some  slight  traces  of 
blood  in  their  bronchial  secretions.  This  cough,  which  is  at  first 
voluntary,  later  becomes  automatic.  The  patient  feels  a  sense  of 
irritation,  a  tickling  in  the  throat,  and  he  gets  into  the  habit  of  keeping 
up  more  or  less  continuously  this  little  dry,  short,  repeated  hacking 
which  is  characterized  by  the  name  of  a  nervous  cough. 

Along  the  same  lines  thoracic  algias  are  developed.  The  false  pul- 
monic, by  reason  of  being  examined  and  palpated,  gets  to  the  point 
where  he  discovers  some  peculiarly  sensitive  region.  The  mental  repre- 
sentation of  this  pain  projects  itself  in  the  form  of  a  localized  pain 
in  the  chest,  accompanied  occasionally  by  a  cutaneous  hyperaesthesia  of 
the  region  where  the  pain  is  felt. 

Other  manifestations  may  still  be  produced  by  a  very  different 
mechanism.  Patients  who  believe  themselves  to  be  attacked  in  their 
respiratory  tracts  have  an  intense  fear  of  catching  cold.  They  get 
what  has  been  called  cold  phobias.  They  load  themselves  with  clothing, 
wearing  two  or  three  coats,  which  they  take  off  and  put  on  when  going 
from  one  room  to  another.  When  they  have  their  backs  to  the  fireplace 
they  will  put  something  over  their  chests,  so  that  two  different  parts 
of  their  body  shall  not  experience  any  difference  in  temperature.  If 
they  get  an  idea  that  it  is  cold,  they  show  very  marked  signs  of  anxiety. 
We  have  seen  one  person  who  under  these  circumstances  would  always 
break  out  into  a  profuse  perspiration  on  his  body.  If  he  were  not  able 
to  go  in  and  change  his  linen  immediately,  he  would  be  sick,  and  would 
have  a  bad  cold  for  several  days,  during  which  he  would  coddle  himself. 

Finally,  by  the  attention  which  these  patients  bring  to  bear  upon 
their  respiratory  functions  they  are  liable  to  have  any  of  the  real 
functional  manifestations  which  we  have  just  studied. 


MANIFESTATIONS  IN  THE  RESPIRATORY  APPARATUS.    91 

It  goes  without  saying  that  such  obsessive  preoccupations  seldom 
exist  without  finally  reacting  on  the  general  moral  and  physical  health 
of  the  subject.  Whether  by  reason  of  their  preoccupation  they  neglect 
to  take  sufficient  food,  or  whether  in  accordance  with  medical  advice 
they  eat  too  much,  they  run  the  risk  of  becoming  false  or  even  true 
gastropaths.  Worn  and  depressed,  the  false  pulmonic  may  develop 
true  tuberculosis;  and  finally,  worried  and  distracted  by  his  business 
and  his  preoccupations  and  having  thus  been  made  extremely  emotional, 
he  nearly  always  ends  up  with  a  severe  attack  of  neurasthenia,  if  he 
has  not  been  fortunate  enough  to  have  proper  therapeutic  help  to  stop 
the  development  of  these  things  in  time. 

Let  us  repeat  again,  in  connection  with  such  patients,  what  we 
have  already  said  about  other  phobic  manifestations.  They  are  not 
hypochondriacs.  It  is  an  error  in  interpretation  which  is  at  the  bottom 
of  their  trouble.  They  can  be  perfectly  and  completely  cured  if  one 
can  convince  them  of  their  mistake.  On  the  other  hand,  what  physician 
can  boast  of  ever  having  cured  a  hypochondriac  or  nosomaniac? 

Before  closing  this  'chapter,  there  still  remain  a  few  words  to  say 
about  two  phenomena, — ^namely,  hiccough  and  hysterical  haemoptysis. 
We  have  placed  them  here  for  definite  reasons, — hiccough  because  it  is 
not  properly  speaking  a  respiratory  phenomenon,  and  haemoptysis  be- 
cause it  seems  doubtful  to  us  that  it  really  exists. 

We  know  that  hiccough  is  caused  by  a  sudden  contraction  of  the 
diaphragm.  This  contraction  is  generally  reflex.  It  may  start  from 
the  peritoneum,  or  it  may  have  a  gastric,  oesophageal,  or  respiratory 
origin,  A  purely  neuropathic  hiccough  is  hardly  ever  found  except  in 
hysterics.  After  examining  very  carefully  everything  that  pertains  to 
this  phenomenon,  of  which  we  have  seen  a  certain  number  of  examples, 
we  could  not  help  but  believe,  that  in  these  cases  it  was  due  to  a  more 
or  less  voluntary — or,  if  you  prefer  it,  a  quasi-simulated — contraction. 
Perhaps,  however,  the  mental  representation  created  by  a  real  attack  of 
hiccough  occurring  previously  might  have  been  sufficient  to  cause  it. 
We  would  hardly  dare  either  to  affirm  or  deny  it. 

As  to  hysterical  haemoptysis,  as  in  all  the  so-called  vicarious  haemor- 
rhages,— that  is  to  say,  occurring  instead  of  and  in  the  same  way  as 
menstruation, — we  are  rather  sceptical.  There  is  no  doubt  that  haemop- 
tysis in  hysterics  is  demonstrated,  but  that  these  haemoptyses  might 
not  be  due  to  an  incipient  tuberculosis  is  by  no  means  sure.  In  any 
case,  we  cannot  consider  it  a  sufficiently  well-established  fact  to  be 
placed  with  any  sense  of  surety  among  the  classified  functional  mani- 
festations. 


CHAPTER  V. 

THE  FUNCTIONAL   MANIFESTATIONS  OF   THE  CARDIOVASCULAR  APPARATUS. 

A.  The  Heart. — Of  all  the  bodily  functions  the  circulation  is  per- 
haps that  which  is  least  able  to  be  modified  by  the  will.  Although  one 
may  stop  one's  respiration  to  a  certain  degree,  and  although  a  simple 
mental  representation  without  the  addition  of  any  excitement  or  emotion 
is  able,  as  we  have  seen,  to  hinder  the  process  of  digestion,  there  is  no 
similar  state  of  affairs  in  connection  with  the  circulation.  No  voluntary 
action  or  mental  representation  is  in  itself  able  to  modify  the  cardiac 
contraction,  or  alter  the  rhythm,  or  have  any  effect  upon  its  strength. 

It  is  true  that  the  functional  disturbances  which  bear  directly  upon 
the  heart  and  the  blood-vessels  are  all  dependent  on  emotions.  But,  on 
the  other  hand,  the  same  thing  happens  in  the  case  of  the  heart  that 
we  have  seen  in  the  case  of  the  various  other  parts  of  the  body, — 
namely,  there  are  phobic  manifestations  which  may  be  followed  by  a 
certain  number  of  disturbances.  These  fixations  are  themselves  of  two 
kinds.  Sometimes  the  mental  representation  may  modify  the  cardiac 
rhythm,  but  that  is  when  excitement  or  emotion  intervenes.  Sometimes 
the  real  functional  disturbances  are  connected  with  the  heart  when  the 
latter  shows  no  sign  of  any  objective  trouble.  They  have  to  do  with 
manifestations  which  one  might  designate  as  peri-  or  para-cardiac.  This 
outlines  the  plan  of  our  study,  and  we  shall  take  up  successively — 

1.  Action  of  emotion  on  the  heart. 

2.  Phobias  of  the  heart,  and  pericardiac  phenomena;  remembering 
from  now  on  this  fact,  that  a  phobic  manifestation  may  be  the  starting- 
point  of  emotional  phenomena  and  consecutive  troubles. 

1.  Action  of  Emotion  on  the  Heart. — The  heart  reacts  to  emotion  or 
excitement  in  two  opposite  ways. 

Sometimes,  and  usually  under  the  stress  of  emotional  shocks,  the 
emotion  slows  down  the  heart-beats  until  syncope  is  almost  produced. 

Syncope,  as  a  rule,  is  only  a  symptom.  Nevertheless,  there  may  be 
in  some  people  a  true  specialization  of  the  emotion  which  causes  them 
to  feel  symptoms  of  syncope  on  every  occasion  when  they  are  excited. 
This  is  one  of  the  first  functional  manifestations  which  one  is  apt  to 
meet  in  the  realm  of  the  cardiovascular  apparatus.  Repeated  syncope, 
as  a  matter  of  fact,  rarely  occurs  in  connection  with  cardiac  affections 
properly  so  called.  It  is  much  more  commonly  a  neuropathic  mani- 
festation. 

In  the  immense  majority  of  cases  the  emotion  is  accompanied  by  a 
tachycardia.  The  latter  may  be  extremely  marked.  The  heart  may 
reach  140  to  150  and  even  more  pulsations  a  minute.  The  tachycardia 
92 


c 


THE  CARDIOVASCULAR  APPARATUS.  93 

may  be  accompanied  by  more  or  less  severe  cardiac  distress.  In  such 
cases  tachycardia  is  generally  also  the  result  of  an  emotional  shock. 

When  less  marked,  it  may  be  an  habitual  symptom  of  internal 
emotion.  Sometimes  the  memory  of  an  emotion  or  a  more  or  less  anxious 
waiting  time  or  some  continued  anxiety  will  be  enough  to  cause  a 
tachycardia  without  any  emotional  shock.  There  are  some  patients  who 
seem  to  be  afflicted  with  an  almost  continuous  tachycardia,  which,  how- 
ever, is  characterized  by  this  fact,  that  it  disappears  during  calm  and 
dreamless  sleep.  A  restless  sleep  or  nightmare  will  bring  it  on,  and  it 
frequently  happens  that  patients  troubled  in  this' way  wake  up  with 
tachycardia. 

Emotional  disturbance  of  the  heart  is  usually  accompanied,  on  the 
one  hand,  by  vasomotor  phenomena,  which  we  shall  discuss  further  on, 
and,  on  the  other  hand,  by  respiratory  troubles  (e.g.,  by  polypnœa). 

Rapid  heart-beats,  or  palpitations,  of  which  so  many  patients  com- 
plain, are,  as  a  fact,  only  the  subjective  impression  of  transient  tachy- 
cardias, and  from  this  point  of  view  would  deserve  no  special  mention 
were  they  not  often  the  starting-point  of  more  or  less  intense  phobic 
manifestations. 

Tachycardiac  phenomena  and  syncope  may  often  be  associated  in 
this  sense,  that  under  the  influence  of  an  emotional  shock  a  subject 
may  first  be  taken  with  tachycardia  and  then  more  or  less  suddenly  fall 
into  a  state  of  syncope.  Arrhythmia  may  in  some  cases  be  associated 
with  it,  or  follow  tachycardia.  In  the  nervous  patients  whom  we  have 
studied  arrhythmia  seems  to  us  to  be  nothing  more  than  tachycardia 
of  very  short  duration.  Bradycardia  is  associated  with  syncope. 
Occurring  alone  it  does  not  seem  to  us  to  form  a  functional  manifestation. 

We  shall  not  dwell  upon  the  pathological  physiology  of  these 
phenomena,  nor  on  the  mechanism  of  the  action  of  the  emotions  on  the 
medullary  centres.  W^e  feel  that  the  fact  in  itself  is  interesting  which 
shows  that  under  the  influence  of  an  emotional  shock  or  an  emotional 
idea  the  cardiac  rhythm  is  susceptible  of  change.  It  permits  us,  in 
fact,  to  isolate  one  mechanism  of  the  functional  fixations  which  until 
now  the  various  symptoms  we  have  described  have  not  brought  out  very 
clearly,  because,  as  we  have  already  said,  in  all  the  functions  which 
we  have  hitherto  studied  the  simple  mental  representation  and  voluntary 
activity  might  serve  as  a  basis  of  an  interpretation  of  the  troubles  which 
were  detected. 

2.  Phobic  Manifestations  and  Pericardiac  Fixations. — Phobic  symp- 
toms centred  on  the  heart  are  very  frequently  met  with.  This  is  very 
simply  explained  by  the  facility  with  which  the  heart — or,  what  comes 
to  the  same  thing,  its  neural  mechanism — reacts  to  all  emotional  mani- 
festation. As  there  are  no  individuals  who  do  not  experience  some 
emotions,  there  are  none  who  have  not,  on  some  occasion,  experienced 
emotional  modification  of  the   cardiac  rhythm.     The   emotional  state 


94  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

being,  on  the  other  hand,  as  we  shall  see  later,  distinctly  favorable  to 
the  establishment  of  all  auto-  and  hetero-suggestions,  it  very  frequently 
happens  that  some  exciting  disturbance  accidentally  affecting  his  cardiac 
apparatus  makes  a  very  great  impression  upon  a  patient,  and  he  develops 
a  phobia  concerning  his  heart. 

In  other  cases  ideas  of  heredity  come  in.  In  the  general  opinion 
of  the  public,  heart  disease  is  hereditary.  We  have  seen  numerous 
patients  who,  because  one  of  their  ancestors  had  had  some  cardiac 
affection,  believed  that  they  must  some  day  fall  a  prey  to  a  disease  of 
the  same  nature.  The  sudden  death  of  one's  ancestors  is  particularly 
apt  to  make  such  an  impression.  One  such  patient  whom  we  have 
seen  lived  in  the  perpetual  fear  of  sudden  death,  because  her  father, 
her  maternal  grandfather,  and  her  paternal  grandmother  had  died  in 
this  way.  More  definite  information  regarding  these  ancestors  showed 
that  they  had  quitted  this  life  at  ages  varying  between  eighty-one  and 
eighty-six  years. 

We  must  call  attention  to  the  fact,  in  passing,  that  there  was  a 
certain  period  when  heart  disease  was  very  prevalent.  In  the  melan- 
choly poetry  of  the  generation  of  1830  it  was  considered  quite  the 
thing,  if  one  were  at  all  inclined  to  be  sentimental,  to  believe  that 
one's  heart  was  a  little  weak.  This  has  rather  passed  out  of  fashion. 
One  nevertheless  still  finds  examples  of  it  in  very  emotional  people 
whose  hearts  often  beat  a  little  faster  because  they  feel  too  keenly. 
These  subjects  differ  from  those  who  have  been  impressed  by  some 
emotional  shock,  and  who  develop  phobias  on  account  of  a  fear  of  their 
heart,  in  that  they  nurse  along  their  imaginary  cardiapathy  and  make 
much  of  it,  but  it  is  seldom  that  that  lasts  very  long.  It  is  the  kind  of 
fad  that  passes  away  when  they  find  something  else  to  exercise  their 
imagination  upon. 

In  other  cases,  and  these  are  much  more  frequent,  medical  sug- 
gestion has  been  called  into  play.  There  are  young  people,  for  in- 
stance, who  for  their  whole  life,  or  part  of  it  at  least,  will  carry  about 
the  impression  that  they  have  heart  disease  because,  when  they  were 
growing  up,  they  had  some  of  the  troubles  which  so  frequently  occur 
when  one  grows  too  fast.  Such  are  anaemic  young  girls  who  have  had 
some  haemic  murmurs  which  their  physician  was  ill  advised  enough  to 
tell  them  about,  and  who,  as  a  result,  had  become  convinced  that  they 
were  cardiacs.  There  are  so  many  fine  points  that  may  be  noted  in  a 
very  careful  auscultation,  such  as  a  slightly  dull  sound,  or  a  hint  of 
double  beat,  or  an  abnormal  tone.  It  is  really  a  question  of  extra- 
cardiac  sounds.  The  patient  is  very  carefully  auscultated.  This  is  re- 
peated over  and  over,  perhaps  ten  times,  to  discover  finally  that  there 
is  nothing  the  matter.  There  is,  however,  by  this  time,  really  something 
the  matter,  for  the  patient 's  imagination  has  been  set  going.  He  departs 
with  the  conviction  that  his  heart  is  not  absolutely  normal,  and  begins  to 
elaborate  fancies  which  have  a  far-reaching  effect  on  his  after  life. 


THE  CARDIOVASCULAR  APPARATUS.  95 

Here,  among  a  hundred  others,  we  have  a  case  of  a  chief  of  a 
battalion,  who  had  chosen  the  soldier's  life  as  his  career  and  who  loved 
his  calling,  but  who  for  years  had  been  haunted  by  the  fear  of  sudden 
death.  This  was  because,  twenty  years  before,  while  at  Saint  Cyr  he 
had  had  an  attack  of  rapid  heart-beats  while  performing  some  violent 
physical  exercise.  He  went  to  consult  one  of  the  well-kno^vn  specialists 
of  the  time,  who,  although  assuring  him  that  there  were  no  lesions,  was 
so  unwise  as  to  prolong  his  examination,  and  to  mutter  in  a  low  voice 
remarks  about  the  tone  of  one  of  the  cardiac  sounds.  The  man  was 
convinced  that  his  heart  was  in  a  much  worse  condition  than  the  phy- 
sician was  willing  to  tell  him,  and  his  life  was  completely  spoiled  by  it, 
for  from  that  time  on  he  always  had  a  fear  of  sudden  death,  and  on  that 
account  would  not  marry. 

A  postman  at  Halles,  twenty-eight  years  of  age  and  strongly  built, 
came  one  day  to  the  clinic  of  the  Salpêtrière.  He  had  had  two  attacks 
of  syncope  in  the  street  the  week  before,  and  he  was  convinced  that 
he  had  some  disease  of  the  heart,  for,  he  said,  that  was  the  reason  why 
he  had  been  discharged  on  half  pay  from  military  service.  Now,  his 
heart  was  perfectly  sound;  but,  haunted  by  the  fear  of  his  disease,  he 
was  always  getting  out  of  breath  and  was  continually  obsessed  by  the 
fear  of  dying  suddenly.    He  was  cured,  after  one  conversation. 

Here  we  have  a  patient  in  whom  a  physician  has  discerned  a 
slightly  dry  mitral  sound,  here  is  another  whose  pulse  has  been  found 
a  trifle  slow  or  slightly  tense,  and  they  have  had  their  lives  spoiled 
because  a  physician  has  mentioned  before  them  the  very  unlikely  pos- 
sibility of  mitral  stenosis  or  an  aortic  aneurism.  We  have  seen  hundreds 
of  such  cases,  which  have  always  been  brought  about  by  ill-considered 
medical  advice. 

Under  other  circumstances,  the  heart  is  not  the  organ  in  question, 
but  the  patient's  symptoms  are  such  as  might  be  attributed  to  cardiac 
affections,  and  these  happening  accidentally  become  the  starting-point 
of  a  phobic  fixation.  Slightly  swollen  ankles  in  a  patient  with  varicose 
veins,  a  sensation  of  vertigo,  scanty  urine  during  the  hot  weather, — 
such  things  will  sometimes  be  enough.  But  in  this  class  of  ideas  the 
one  which  most  commonly  plays  the  rôle  of  chief  pathogenic  factor 
is  getting  out  of  breath.  The  number  of  people  who  are  concerned 
by  rapid  breathing  is  very  great.  At  first  it  is  purely  an  accidental 
phenomenon,  connected  with  eating  too  much,  or  with  not  knowing  how 
to  breathe  during  any  prolonged  effort.  Then,  when  the  attention 
has  become  centred  upon  this  habit  of  panting,  the  patient  feels  the 
functional  respiratory  fixations  of  which  we  have  spoken,  but  he 
attributes  the  panting  to  his  heart,  and  all  the  more  when  the  panting 
is  accompanied  by  a  purely  physiological  tachycardia  which  is  its  neces- 
sary companion. 

Under  these  various  influences  many  patients  are  seized  with  a 
profound  conviction  that  they  have  some  heart  lesion.  Other  mechanisms 


96  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

are  liable  to  make  the  person  believe  that  he  has  angina  pectoris.  All 
precordial  pains  and  even  those  that  are  more  remote  are  especially  apt, 
by  following  the  genetic  mode  that  we  have  already  studied,  to  serve 
as  a  starting-point  of  the  psychic  fixation.  An  intercostal  neuralgia, 
a  stitch  in  the  side,  or  even  a  rheumatic  pain  in  the  left  shoulder  is 
sufficient  for  a  foundation.  These  being  the  principal  sources  of  phobic 
manifestations,  how  do  the  patients  who  are  suffering  from  them  react? 

Sometimes  these  patients  remain  simple  phobies.  They  do  not 
develop  any  particular  phenomenon  of  cardiac  or  pericardiac  fixation. 
These  are  pure  psychics,  whose  lives  are  practically  spoiled  by  the 
conviction  that  they  are  in  a  very  precarious  condition  on  account  of 
their  hearts.  This,  in  fact,  is  the  most  frequent  expression  of  their 
trouble.  We  must  repeat,  in  connection  with  these  patients,  what  we 
have  already  said  concerning  our  other  phobies, — namely,  that  they  are 
in  no  sense  of  the  word  hypochondriacs  or  nosomaniacs.  Often,  in 
fact,  they  are  people  who  are  of  naturally  a  gay  temperament,  who 
would  ask  nothing  more  than  to  be  able  to  enjoy  all  that  there  is  in 
life,  but  who,  either  spontaneously  or  as  the  result  of  some  medical 
suggestion,  have  misinterpreted  an  accidental  phenomenon  of  their  life, 
and  have  ever  since  dwelt  shrouded  in  their  error.  But  these  latter 
always  have  a  starting-point.  When  cured  by  persuasion,  these  patients 
become  definitely  well  in  contrast  to  the  hypochondriacs  or  nosomaniacs. 
They  are  what  we  might  call  accidental,  but  not  constitutional  noso- 
phobics. 

Frequently,  however,  the  phenomena  are  complicated.  Two  examples 
will  enable  us  to  grasp  the  way  in  which  such  complications  occur. 

Mr.  X.,  fifty-five  years  of  age,  came  to  one  of  us  on  account  of 
attacks  of  tachycardia,  which  would  come  on  without  any  appreciable 
cause,  and  last  for  a  time  varying  from  a  few  minutes  to  several  hours. 
These  attacks  would  come  on  at  any  time  whatever,  as  frequently  in 
the  day  as  in  the  night.  They  were  accompanied  by  polypnœa,  a 
sensation  of  smothering,  and  pains  that  were  more  or  less  sharp.  The 
patient  also  complained,  outside  of  his  periods  of  attack,  of  sensations 
of  vertigo,  with  the  feeling  that  his  legs  were  giving  way  beneath  him. 

There  were  no  hereditary  nor  personal  pathological  antecedents. 
The  objective  examination  was  without  results.  The  heart  was  per- 
fectly healthy;  the  sounds  were  distinct  and  well-marked.  There  were 
no  murmurs  nor  extraneous  noises.  Percussion  showed  no  dilation  nor 
displacement  of  the  aorta.  The  urine  was  normal.  The  arterial  tension 
was  170. 

Here  we  have  a  case  of  real  paroxysmal  tachycardia  or  an  imita- 
tion of  the  same.  What  really  was  the  matter?  The  patient  had  been 
subjected  to  a  very  sharp  rebuke  from  one  of  his  employers.  After 
the  tirade  was  finished,  on  entering  his  office  he  had  had  an  attack  of 
vertigo  and  tachycardia,  and  association  was  immediately  set  up.  The 
patient  said  to  himself,  ''It  is  because  I  am  ill  that  I  have  not  been 


THE  CARDIOVASCULAR  APPARATUS.  97 

able  to  do  my  work  as  well  as  in  the  past."  He  went  home.  In  the 
middle  of  the  night  he  wakened  with  nightmare.  He  felt  his  pulse 
and  found  it  very  rapid.  From  that  time  on,  in  season  and  out  of 
season,  he  was  seized  with  these  attacks  of  tachycardia.  Soon  there 
occurred  the  added  phenomena  of  anxiety  and  of  precordial  pains.  He 
believed  that  he  had  angina  pectoris.  His  daily  duties  became  impos- 
sible for  him,  and  he  was  on  the  point  of  sending  in  his  resignation. 
His  condition  became  still  worse.  He  could  no  longer  go  out  without 
being  seized  with  attacks  of  vertigo,  with  tachycardia  and  panting. 

A  few  days  of  rest  interspersed  with  several  psychotherapeutic 
conversations  were  enough  to  control  these  troubles. 

An  emotional  attack  as  the  starting-point,  consequent  phobia  of 
the  heart,  then  the  reproduction  by  emotional  ideas  of  the  same  symp- 
toms, to  which  were  added,  by  mental  representation,  precordial  pain 
and  very  pronounced  vertigo, — such  was  the  succession  of  phenomena 
in  this  patient. 

Another  patient,  Madame  X.,  thirty-eight  years  of  age,  was  attacked 
by  a  combination  of  symptoms  which  were  pronounced,  by  a  physician 
of  Paris,  and  not  one  of  the  least  known,  to  be  angina  pectoris.  Here 
we  have  the  whole  succession  of  facts  as  they  occurred  to  this  lady, 
whose  case  is  quite  like  the  preceding  one. 

Her  husband,  with  whom  she  did  not  live  happily,  was  an  invalid 
and  afflicted  with  a  very  repugnant  disease,  which  created  in  our  patient 
a  series  of  emotional  disturbances,  under  the  influence  of  which  she  fell 
into  a  very  marked  hystero-neurasthenic  state,  with  violent  headache, 
loss  of  weight,  and  a  state  of  general  asthenia,  etc.  In  addition  to 
these  latter  symptoms  she  perceived  that  when  she  was  upset  her 
heart  beat  more  rapidly.  She  was  concerned  about  this  and  went  to  a 
physician,  who. asked  her  if  she  did  not  have  painful  symptoms,  and  a 
feeling  of  heaviness  in  the  left  arm,  etc.  It  goes  without  saying  that, 
under  this  suggestive  influence,  the  phenomena  he  was  looking  for  soon 
made  their  appearance.  She  then  consulted  a  specialist  in  heart  dis- 
eases, to  whom  she  gave  in  recounting  the  history  of  her  case  the  whole 
symptomatology  to  which  she  had  attained.  He  made  the  diagnosis  of 
angina  pectoris — *' possibly  neuropathic,"  he  added.  The  patient 
naturally  was  all  the  more  impressed.  The  symptoms  increased,  and 
the  attacks  with  tachycardia,  pain,  and  angina  continued. 

On  examining  this  lady,  we  found  a  slight  left  hysterical  hemiplegia, 
which,  in  conjunction  with  the  circumstances  of  the  beginning  of  her 
trouble,  threw  some  light  on  the  diagnosis.  It  is  quite  probable  that 
this  hemiplegia  was  brought  about  under  the  influence  of  medical  sug- 
gestion which  we  have  just  related.  This  influence  in  fact  explains  the 
heaviness  felt  in  the  patient's  arm,  but  it  does  not  integrally  explain 
the  other  motor  symptoms,  for,  as  a  matter  of  fact,  the  leg  was  included 
in  the  paralysis.  The  patient  had  never  noticed  it,  nor  had  she  com- 
plained of  it,  and  it  was  only  by  the  difference  in  the  wearing  out  of 
7 


98  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

her  shoes  that  we  were  able  to  convince  her  of  the  reality  of  a  trouble 
which  was  elsewhere  shown  objectively  by  diminution  of  muscular 
strength.    A  distinct  hemianaesthesia  was  associated  with  the  hemiplegia. 

Here,  then,  is  a  case  where,  under  the  double  influence  of  emotional 
phenomena  and  suggestion,  we  can  see  how  a  whole  series  of  secondary 
disturbances  may  be  built  up  around  a  cardiac  phobia. 

Under  other  circumstances  we  have  seen  a  cardiac  phobia  creating 
by  the  same  mechanisms  conditions  of  astasia-abasia  having  as  a  start- 
ing-point a  mental  representation  of  vertigo.  Elsewhere  the  symptoms 
of  vertigo  exist  alone;  in  other  cases  it  is  a  very  rapid  panting  which 
produces  them  ;  in  still  others  the  patients  complain  of  congestive  pres- 
sure, etc. 

If  we  now  try  to  sum  up  what  has  gone  before,  we  shall  see  that 
cardiac  phobias  may  occur  as  the  result  of  emotional  accidents  or  morbid 
convictions  from  many  sources.  Then,  under  the  influence  of  emotional 
ideas,  the  various  effects  that  emotion  may  exercise  on  the  heart  are 
produced  or  reproduced.  Finally,  under  the  effect  of  mental  repre- 
sentations which  are  auto-  or  hetero-suggestive  in  their  nature,  there 
will  surge  up  numerous  secondary  pericardiac  or  paracardiac  symp- 
toms. The  commonest  of  these  are  precordial  pains  or  symptoms  of 
vertigo.  But,  as  in  aU  manifestations  of  this  kind,  they  may  be 
extremely  diverse,  and  give  rise  to  the  most  unexpected  associations. 

B.  Vascular  Manifestations. — Here  again  the  same  division  may 
be  adopted,  and  we  can  describe  the  effect  of  emotion  on  the  vascular 
phenomena,  on  the  one  hand,  and,  on  the  other,  the  phobic  manifesta- 
tions which  may  be  associated  with  vascular  affections. 

Is  it  possible  for  emotion  to  have  any  effect  upon  the  large  vessels? 
The  thing  is  possible,  but  has  not  be,en  proved,  and  we  feel  that  the 
arterial  throbbings  which  many  patients  complain  of  when  under  ex- 
citement bear  some  relation  to  the  modifications  of  cardiac  contraction. 

On  the  other  hand,  nothing  is  so  common  as  vasomotor  disturbances 
caused  by  excitement.  The  emotion  or  excitement  acts  upon  the 
vasomotor,  in  two  different  ways, — either  by  vasodilatation  or  vaso- 
constriction. Vasodilatation  is  the  more  common,  and  is  seen  by  the 
blood  rushing  to  the  face.  It  occurs  only  in  slight  emotions,  more 
specially  perhaps  in  connection  with  emotional  ideas  depending  on 
purely  internal  emotion.  Every  one  knows  people  who  blush  at  every- 
thing and  nothing.  We  have  seen  patients  of  this  kind  to  whom  it  was 
a  real  infirmity,  who  blushed  every  time  any  one  spoke  a  word  to  them, 
and  whose  social  life  was  thereby  peculiarly  hampered.  We  have 
seen  women  who  would  plaster  their  faces  with  layers  of  paint  to  try 
to  cover  up  this  trouble.  In  their  case  the  very  fear  of  blushing  would 
of  itself  bring  it  on.  They  were  annoyed  not  only  from  the  point  of 
view  of  secondary  interpretations  to  which  their  blushes  might  give 
rise,  but  from  the  aesthetic  point  of  view.     True  erythrophobias  arise 


THE  CARDIOVASCULAR  APPARATUS.  99 

in  this  way,  mixed  manifestations  where  the  emotion  plays  a  rôle,  but 
where  the  mental  representation  is  sure  to  come  in  also  as  a  factor. 
Here  is  an  important  point  from  the  doctrinal  aspect, — namely,  that  a 
simple  mental  representation  is  enough  to  create  vasomotor  disturbances 
of  this  kind.  It  is  wholly  a  question  of  vasomotor  disturbance  and 
hysterical  œdemas  which  is  to  be  solved  in  such  cases. 

The  vasodilatation  may  not  be  confined  to  the  face:  it  may  spread, 
flushing  the  neck  and  extending  down  to  the  breast,  like  the  blush  of 
shame.    It  is  very  rarely  observed  anywhere  else. 

Vasoconstriction  is  a  phenomenon  which  is  observed  in  emotional 
shock.  The  pallor  of  the  face,  which  may  become  absolutely  bloodless, 
and  general  paleness  of  the  skin  are  classic  signs  of  great  emotion.  They 
may  also  play  a  rôle  in  the  production  of  syncope  by  too  great  a  flow 
of  blood,  or,  by  their  action  on  the  irrigation  of  the  bulbar  centres, 
etc.,  a  rôle  also  in  the  production  of  tachycardia. 

Is  there  such  a  thing  as  localized  vasoconstriction?  This  is  the 
same  problem  as  that  of  the  dilatations,  but  we  shall  take  up  these 
questions  when  we  study  the  functional  manifestations  which  affect  the 
skin,  and  all  that  we  shall  do  now  is  to  retain  these  two  facts, — 
namely,  that  under  the  influence  of  slight  emotion  or  emotional  repre- 
sentations, vasodilatations  arise  which  are  usually  confined  to  the  face, 
on  the  one  hand,  and,  on  the  other  hand,  the  existence  of  vasocon- 
striction which  may  or  may  not  be  confined  to  the  face,  as  a  result  of 
emotions  which  are  more  often  strong  and  sudden.  We  may  add  that 
there  are  individuals  who,  apropos  of  slight  emotion,  will  pale  while 
others  blush;  but  the  fact  is  rare,  and,  as  a  rule,  there  must  be  some 
emotion  of  external  origin,  or  such  a  strong  internal  emotion  as  anger 
to  cause  such  phenomena. 

Phobic  manifestations  which  have  an  effect  upon  the  vascular 
apparatus  constitute  a  group  which  is  wholly  modem  in  its  creation. 
For  this  the  great  extension  given  to  the  conception  of  arteriosclerosis 
is  responsible.  To  this  extension  the  medical  press  as  well  as  the  daily 
papers,  by  spreading  abroad  communications  of  scientific  societies,  have 
assisted  in  impressing  upon  the  minds  of  many  laymen  as  well  as  of 
physicians  extreme  ideas  concerning  the  importance  of  such  a  diathesis. 
To  the  multiplicity  of  therapeutic  means  must  be  attributed  in  some 
degree  the  multitude  of  patients,  and  the  excessive  advertisement  of  all 
kinds  of  medical  or  physical  treatments  for  arteriosclerosis  has  called 
forth  a  remarkable  growth  in  the  number  of  devotees  to  this  or  that 
therapeutic  method. 

We  have,  for  our  own  part,  seen  a  great  number  of  patients  who, 
because  their  arterial  tension  was  raised  a  millimetre  too  high,  had  had 
their  minds  directed  by  physicians  to  the  idea  of  precocious  arterio- 
sclerosis, sometimes  more  or  less  generalized  or  more  or  less  localized. 
It  goes  without  saying  that,  from  that  time  on,  these  patients  are  con- 


100  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

tinually  examining  themselves,  and  end  by  really  experiencing  a  whole 
series  of  difficulties  of  mental  origin  in  their  different  organs. 

We  have  seen  a  patient  oriented  in  this  way  by  his  physician  on 
the  probable  arteriosclerosis  of  the  spinal  cord,  who  experienced  one 
after  another  all  the  phenomena  of  astasia-abasia. 

Others  listen,  as  it  were,  for  their  arterial  pulsations.  When  their 
head  is  on  the  pillow  they  try  to  see  if  they  can  perceive  the  carotid 
pulsation.  They  finally  get  to  the  point  where  they  can  hear  their  pulse, 
and  by  that  time  they  have  developed  insomnia.  Others  are  continually 
feeling  their  pulse  in  order  to  note  the  supposed  or  real  hypertension,  etc. 

Does  this  mean  that  we  mistake  the  real  and  frequent  existence  of 
arteriosclerosis?  Certainly  not,  but  we  think  that  the  physician  ought 
in  his  diagnosis  to  take  into  consideration  the  mentality  of  his  patients 
and  to  realize  that  the  word  arteriosclerosis  is  a  very  dangerous  one  to 
speak  at  the  present  day,  because  the  public  at  large  is  too  much 
informed,  and  too  badly  informed,  concerning  this  affection  and  its 
immediate  or  remote  consequences.  Under  these  conditions  it  is  very 
sure  that  such  a  diagnosis  will  throw  the  patient  into  a  state  of  excite- 
ment which  will  be  apt  to  lead  to  a  number  of  secondary  manifestations. 

Other  neuropathic  disturbances  may  arise  from  the  idea  of  a  possible 
aneurism,  even  from  the  greater  uneasiness  caused  by  superficial  or 
deep-seated  varicose  veins,  etc.  We  will  not  dwell  further  upon  this, 
however. 

This  brings  us  to  the  end  of  the  study  of  the  functional  manifesta- 
tions which  may  act  upon  the  cardiovascular  apparatus.  We  have 
confined  our  description  to  those  manifestations  which  we  consider  to 
be  undoubtedly  functional  in  their  nature, — that  is  to  say,  connected 
with  the  phenomena  of  emotion  or  due  to  some  external  interpretation 
or  mental  conception. 

But  there  is  a  whole  series  of  other  vascular  disturbances  which 
would  lead  to  numerous  discussions,  and  which  we  have  purposely 
neglected.  Without  mentioning  vasomotor  troubles  which  we  shall  take 
up  elsewhere,  we  have  in  this  chapter  passed  by  many  phenomena 
which  although  neuropathic  in  their  nature  are  none  the  less  functional 
manifestations.  We  have  not  spoken  of  painful  palpitations,  properly 
so  called,  nor  of  arrhythmias,  nor  of  neuropathic  angina  pectoris,  which 
is  sometimes  very  difficult  to  distinguish  from  real  angina,  nor  of 
essentially  paroxysmal  tachycardia,  nor  visceral  haemorrhages  of  hys- 
terics, nor  cyanosis  of  the  extremities.  That  violent  or  repeated  or 
continuous  emotion,  and  even  mental  representations  when  firmly  fixed, 
may  be  able  to  influence  such  affections  is  most  assuredly  possible.  But 
it  seems  to  us  rather  far-fetched  to  place  them  in  the  list  of  facts 
which  we  have  just  been  describing. 


CHAPTER  VI. 


CUTANEOUS  FUNCTIONAL  SYMPTOMS. 


The  functional  symptoms  localized  in  the  skin  are  extremely  com- 
plex. By  their  number  and  variability,  as  well  as  their  pathogenic 
interpretations  and  the  discussions  to  which  they  have  given  rise,  they 
assume  a  rank  of  first  importance,  a  rank  which,  however,  is  much  more 
theoretic  than  practical. 

For  convenience  in  description  we  shall  take  up  successively — 

1.  Action  of  the  emotions  on  the  skin  and  the  cutaneous  functions, 

2.  Vasomotor  symptoms, — lasting  secretory  or  trophic,  diffused  or 
localized. 

3.  Phobic  phenomena  and  their  consequences. 

In  a  separate  chapter  we  shall  take  up  disturbances  of  general  sen- 
sibility, mixed  symptoms  which  are  cutaneous  in  their  localization  and 
nervous  in  nature. 

1.  Action  of  Emotion  on  the  Skin  and  the  Cutaneous  Functions. — 
The  cutaneous  symptoms  which  may  be  observed  under  the  influence  of 
emotion  are  numerous.  Here,  again,  emotion  may  work  in  two  different 
ways,  according  to  whether  it  is  a  case  of  emotional  shock  from  an 
external  cause  of  some  sort,  or  whether  it  is  a  case  of  emotional  repre- 
sentations,— or  internal  emotion,  if  one  so  prefers  to  call  it. 

Of  all  these  fixations,  the  commonest  and  the  most  classic,  we 
might  almost  say  the  mest  literary,  is  the  well-known  symptom  of 
horripilation,  or  goose-flesh.  It  is  formed  by  the  raising  up  of  the 
pilary  system.  These  are  the  individuals  whose  hairs  rise  on  their 
heads,  whose  flesh  creeps.  This  symptom  always  arises  under  the  in- 
fluence of  fear,  or,  as  its  name  indicates,  of  some  horror.  It  may  be  a 
dramatic  play,  or  the  sight  of  an  accident,  or  listening  to  the  description 
of  some  scene  of  horror  which  causes  it.  It  often  has  to  do  with  cir- 
cumstances quite  apart  from  the  individual,  and  which  do  not  directly 
concern  him.  This  phenomenon,  reduced  to  its  simplest  expression,  is 
nothing  more  than  a  sensation  which  amateur  lovers  of  dramatic  spec- 
tacles like  to  feel.  When  it  is  a  case  of  intense  emotional  shock  where 
the  individual  is  personally  and  directly  involved,  horripilation  rarely 
occurs  alone,  but  is  accompanied  by  many  other  manifestations. 

Superficial  vasoconstriction  is  a  phenomenon  which  also  frequently 
attends  any  great  emotional  shock.  People  express  it  by  saying  that 
they  felt  "their  blood  freeze  in  their  veins.''  It  is  accompanied  by 
general  pallor  of  the  skin.  More  often  it  is  associated  with  a  tendency 
to  faint. 

101 


102  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

Superficial  vasodilatation  also  has  its  colloquial  expression.  People 
say  that  they  ''turned  hot"  when  speaking  of  an  emotion  or  an 
emotional  representation  where  this  phenomenon  occurred,  which,  how- 
ever, really  belongs  to  emotions  of  moderate  intensity  rather  than  to 
great  emotional  shocks. 

Vasodilatation  and  vasoconstriction  may  or  may  not  be  accom- 
panied by  secretory  disturbances  of  the  sweat-glands.  Generalized 
hyperidrosis  as  a  result  of  emotion  is  one  of  the  commonest  occurrences. 
One  may  break  out  into  hot  perspiration  or  cold  perspiration  follow- 
ing vasodilatation  or  vasoconstriction  associated  with  secretory 
disturbance. 

Vasomotor  and  localized  secretory  symptoms  may  be  transiently 
produced  under  the  same  kind  of  influence.  We  have  already  spoken 
of  the  flushing  and  paling  of  the  face.  This  symptom  is  commonly 
expressed  by  saying  "I  turned  red,"  "I  turned  as  white  as  a  sheet," 
etc.  Perspiration  of  one  part  alone  may  also  be  observed.  Here  again 
it  is  usually  the  face  alone  which  is  affected.  Under  the  influence  of 
shame,  or  any  other  emotional  cause,  such  as  fear,  for  example,  one 
will  find  that  other  surfaces  are  affected  by  localized  hyperidrosis, — 
the  palms  of  the  hands,  the  armpits,  the  breast,  the  genital  and  peri- 
genital  regions,  and  sometimes  the  entire  cutaneous  surface.  However 
it  may  be,  we  have  seen  that  under  the  influence  of  emotional  shock, 
or  accidental  emotional  representation,  the  following  phenomena  may 
be  produced  :  horripilation,  vasomotor  and  secretory  disturbances.  These 
are  facts  to  be  remembered,  for  we  shall  have  occasion  frequently  to 
refer  to  them  in  the  following  paragraphs. 

2.  Lasting  Vasomotor,  Secretory,  or  Trophic  Symptoms,  hoth  Diffused 
and  Localized. — In  this  field  all  the  manifestations  which  emotion  causes 
are  transient  as  the  emotion  itself.  But  the  time  was,  and  it  is  only 
just  beginning  to  slip  into  the  past,  when  major  hysteria  was  cul- 
tivated, when  it  was  customary  to  describe  a  great  number  of  lasting 
vasomotor,  secretory,  or  trophic  fixations  which  were  considered  as  of  a 
functional  neuropathic  nature.  For  some  years  now,  the  existence  even 
of  these  troubles  has  been  vigorously  attacked.  Babinski,  in  particular, 
has  refused  to  admit  them.  According  to  this  author,  hysteria  is  no 
longer  the  great  simulator,  to  use  Charcot's  expression,  but  it  is  the 
hysteric  who  is  the  great  simulator.  Trophic,  secretory,  and  vasomotor 
disturbances  are,  according  to  Babinski,  created  by  conscious  suggestion, 
^or  in  other  terms  by  simulation.  In  circumstances  favorable  for  their 
observation  and  where  there  is  no  chance  of  subterfuge,  they  do  not  occur, 
no  more  than  do  the  troubles  of  sensibility.  This  is  in  fact  almost  the  same 
thing  as  the  conception  which  was  some  time  ago  set  forth  by  Bernheim, 
who  limited  hysteria  to  the  crisis  itself.  In  support  of  his  doctrine, 
Babinski  states  that  personally  he  has  never  been  able  to  observe  any- 


CUTANEOUS  FUNCTIONAL  SYMPTOMS.  103 

thing  analogous  to  the  various  troubles  of  this  kind  of  which  we  are 
speaking. 

Nevertheless,  if  we  turn  back  to  the  old  nomenclatures,  these  troubles 
would  be  extremely  diverse  and  very  frequent.  Let  us  first  of  all 
enumerate  them. 

Those  that  belong  to  the  disturbances  of  the  sweat-glands  are 
bromidrosis  (perspiration  with  odor),  chromidrosis  (colored  perspira- 
tion), haematidrosis  (bloody  perspiration),  phosphorescent  perspiration, 
generalized  hyperidrosis,  localized  hyperidrosis,  or  ephidrosis,  all  of 
which  have  been  in  their  turn  described  and  studied. 

The  cutaneous  trophic  disturbances  which  form  urticaria,  white, 
blue,  rose,  or  red  œdema,  pemphigus,  hysterical  eczema,  gangrene  of 
the  skin,  disturbances  of  pigmentation,  vitiligo,  lentigo,  lichen,  whiten- 
ing of  the  hair,  atrophy  and  falling  of  the  hair,  hypertrophy  of  the 
pilary  system,  and  onychia  have  all  been  frequently  mentioned  and 
considered  as  hysterical  in  nature. 

In  the  vasomotor  disturbances  we  may  place  hasmatidroses,  or  bloody 
perspirations,  haemorrhages  which  occur  without  any  lesion,  ecchymoses, 
and  finally,  and  above  all,  the  classic  haemorrhages  to  which  have  been 
given  the  name  stigmata  (the  production  of  marks  of  wounds  recalling 
in  their  arrangement  the  wounds  of  Jesus  Christ  upon  the  cross),  as 
in  the  case  of  St.  Francis  of  Assisi  and  Louise  Lateau. 

Trophic  and  vasomotor  disturbances  may  be  associated  and  haemor- 
rhages may  follow  bulbous  eruptions  and  œdemas,  etc.  The  majority 
of  these  latter  troubles  occur  after  hysterical  dreams,  in  which  are 
presented  to  the  patient's  mind  either  the  lesions  themselves  or  causes 
which  are  likely  to  create  these  lesions. 

On  each  one  of  these  troubles,  chapters  and  even  volumes  have  been 
written,  quite  as  many  in  France  as  in  other  countries.  Charcot  and 
the  majority  of  his  pupils  have  described  them  at  great  length  and  have 
considered  them  as  having  an  unquestionable  reality.  Could  all  these 
careful  observers,  even  men  of  genius,  have  been  the  playthings  of 
deceivers,  and  taken  in  by  suggestions  of  which  they  themselves  and 
not  their  patients  were  the  prey? 

It  is  very  certain  that  we  are  much  more  reserved  to-day  in  ex- 
pressing our  opinion  upon  the  existence  of  true  trophic  cutaneous  dis- 
turbances in  hysteria,  and  that  one  must  be  more  suspicious  than  ever 
of  simulation.  We  may  frankly  say,  we  must  be  systematically  sus- 
picious. In  any  case,  these  troubles,  if  they  do  exist,  are  by  no  means 
as  common  as  they  were  thought  to  be  not  so  very  long  ago.  On  one 
point,  however,  everybody  is  agreed,  and  that  is  that  it  is  evident  that 
the  former  intensive  method  of  cultivating  hysteria  was  of  such  a 
nature  as  to  give  peculiar  encouragement  to  the  art  of  simulation. 

Other  arguments  may  be  brought  to  bear.  First  of  all,  the  absolute 
proof  of  deception  in  a  great  many  cases,  and  of  such  clever  fraud 
that  it  sometimes  required  great  subtlety  to  detect  it,  must  in  itself  > 


104  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

have  a  bearing  on  the  subject.  It  is  always  the  case  in  medicine, 
quite  contrary  to  the  exact  sciences,  that  negative  facts  count  for  nothing 
and  positive  facts  only  have  the  value  of  proof.  We  note  the  relative 
frequency  of  troubles  in  the  regions  which  the  patients  can  readily 
reach, — the  hand,  the  arm,  the  breasts,  the  thighs, — and,  on  the  other 
hand,  the  rareness  with  which  they  occur  in  regions  which  are  more 
difficult  to  reach,  such  as  the  back,  for  example.  We  also  note  that  the 
troubles  observed  often  bear  a  peculiar  resemblance  to  lesions  made 
by  compression,  by  burns,  or  by  blisters,  which  are  the  mechanisms 
most  often  employed  by  simulators. 

In  the  same  way,  if  one  admits  Babinski's  conception,  we  find  that 
the  troubles  in  phenomena  of  this  kind  would  not  be  confined  to  the 
periphery.  What  we  ought  to  study  is  the  mental  condition  which 
will  engender  a  simulation  which  is  sometimes  wholly  disinterested, 
sometimes  even  injurious  and  dangerous  for  the  patient,  such  as  was 
the  case  of  a  patient  of  Dieulafoy  who,  although  a  real  self-mutilator, 
allowed  himself  to  have  an  amputation  performed  for  the  trophic  dis- 
turbances which  simulation  had  engendered. 

There  are  always  some  facts  of  which  simulation  could  not  be  the 
cause, — for  example,  muscular  atrophy,  which  is  not  seldom  found  in 
hysterical  contractures  and  paralytics,  and  which  may  sometimes  be  very 
pronounced. 

The  same  thing  occurs  also  for  the  fibromuscular  retractions  in  the 
case  of  hysterical  contractures  which  have  lasted  a  long  time.  Such  are 
the  fibromuscular  retractions  of  the  adductors  which  are  observed  in 
the  case  of  old  contractures  of  these  muscles,  and  which,  as  we  have 
had  personal  opportunity  to  see,  can  only  be  broken  up  with  great 
difficulty,  under  the  influence  of  chloroform.  Such,  again,  are  the 
fibromuscular  retractions  of  the  sole  of  the  foot  which  are  seen  in 
hysterical  contractures  of  the  lower  limbs  dating  back  a  long  time,  and 
which  are  quite  as  intense  as  those  which  one  finds  in  cases  of  peri- 
pheral neuritis  (particularly  in  alcoholic  cases),  when  they  have  neg- 
lected to  move  the  joints  of  the  foot  every  day.  These  fibromuscular 
retractions  of  the  ball  of  the  foot  may  persist — ^we  have  seen  several 
examples  of  them — even  after  the  contracture  is  cured,  and  sometimes 
hinder  the  patient  so  much  in  walking  that  surgical  intervention  may 
be  necessary.  In  truth,  it  seems,  from  our  way  of  looking  at  things, 
that  hysteria,  just  like  neurasthenia,  consists  rather  in  a  peculiar  ante- 
cedent mental  state  than  in  the  accidents  of  any  kind  which  seem  to  us 
essentially  secondary.  Nevertheless,  if  we  withdraw  from  the  ancient 
classical  opinion,  which  admits  the  reality  and  the  frequency  of  trophic 
vasomotor  and  secretory  disturbances  in  hysteria,  we  are,  however, 
not  ready  to  adopt  such  an  absolutely  exclusive  attitude  as  Babinski's. 

We  might  on  this  point  sum  up  our  opinion  in  the  following  manner. 
All  the  phenomena  which  emotion  or  emotional  representations  are 
capable  of  creating  in  a  transitory  fashion  are  susceptible  of  existing 


CUTANEOUS  FUNCTIONAL  SYMPTOMS.  105 

in  a  lasting  form  in  a  psychoneurosis,  whether  they  occur  as  hysterical 
phenomena,  or  neurasthenic  phenomena,  or  associated  phenomena. 

Without  entering,  for  the  time,  into  a  theoretic  discussion  of  this 
proposition,  let  us  confine  ourselves  simply  to  facts.  Concerning  cases 
of  ecchymosis,  or  hysterical  haemorrhages,  stigmata,  and  cases  of  œdema, 
we  must,  as  a  matter  of  truth,  state  that  we  have  not  sufficient  positive 
knowledge  concerning  them. 

On  the  other  hacd,  we  have  been  able  to  prove  a  certain  number  of 
cases  where  the  vasomotor  phenomena  or  the  secretory  phenomena 
were  produced,  without  any  possible  chance  of  simulation,  by  simple 
mental  impressions.     We  can  only  quote  a  few  of  them. 

Mr.  X.,  sixty  years  of  age,  was  afflicted  with  a  phobia  of  cold,  of 
which  we  have  already  spoken  in  connection  with  respiratory  manifesta- 
tions. Very  well.  In  the  case  of  this  patient  we  have  been  able  to 
prove  the  objective  existence  of  superficial  vasoconstriction  associated 
with  abundant  hyperidrosis  :  the  skin  would  be  cold  where  a  few 
moments  before  it  was  of  a  normal  temperature.  The  phenomenon 
was  produced  the  moment  a  mental  impression  of  the  possibility  of 
catching  cold  occurred.  The  mentality  of  this  patient  was,  moreover, 
not  that  of  an  hysteric,  but  rather  of  a  neurasthenic. 

In  the  case  of  a  patient  in  private  practice,  the  mother  of  a  family, 
thirty-eight  years  of  age,  and  afflicted  with  absolute  and  flaccid  hysterical 
paraplegia,  one  of  us  observed,  over  and  over  again,  that,  under  the 
influence  of  an  emotional  condition  of  a  very  peculiar  nature  brought 
about  by  the  fear  of  an  intimate  psychanalytic  confession,  there  would 
arise  vasomotor  troubles  of  really  extraordinary  intensity.  The  skin 
of  the  entire  body  became  cold,  and  the  extremities  of  the  limbs,  the 
hands  and  feet,  turned  bluish  black,  as  if  they  had  been  dipped  in 
aniline  ink,  or  as  if  the  patient  had  taken  an  overdose  of  phenacetin. 
Then  the  whole  surface  of  the  skin  would  break  out  into  an  excessive 
cold  perspiration. 

In  the  case  of  another  patient,  sixteen  years  old,  whom  we  saw  in 
one  of  our  services  at  the  Salpêtrière,  and  who  had  been  under  treatment 
for  hysterical  paraplegia  for  months,  but  who  was  cured  in  a  few  weeks, 
the  following  facts  occurred.  When  lying  in  bed,  the  lower  limbs 
seemed  normal  ;  but  when  she  was  told  to  get  up  and  try  to  walk,  under 
the  influence  of  the  emotions  caused  by  the  idea  of  the  effort  she  was 
to  make,  her  limbs  and  her  thighs  immediately  turned  purple.  A  very 
marked  vasodilatation  had  taken  place,  which  grew  still  worse  when 
the  patient  was  standing.  In  this  particular  case  there  could  be  no 
question  of  simulation,  or  of  compression  by  any  constriction  whatsoever 
about  the  thighs,  for  the  phenomenon  was  developed  and  increased,  as 
it  were,  under  the  very  eyes  of  the  observer. 

In  the  three  cases  which  we  have  just  outlined,  it  was  a  question 
really  of  emotional  recollections  under  the  influence  of  a  mental  repre- 
sentation, and  that,  according  to  our  way  of  thinking,  is  the  usual 


106  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

mechanism  in  this  whole  category  of  disturbances.  They  have  nothing 
to  do  with  suggestion.  These  are  what  one  might  describe  as  specialized 
emotional  phenomena,  which  always  occur  in  identically  the  same  way 
under  the  influence  of  the  emotion.  They  disappear  when,  under  treat- 
ment, the  idea  loses  its  emotional  dependence. 

These  are,  therefore,  repeated  disturbances  rather  than  lasting  dis- 
turbances, in  the  proper  sense  of  the  word. 

It  is  very  evident  that,  theoretically,  the  continuity  of  any  emotional 
representation  whatsoever  is  apt  to  lead  to  continuity  of  the  emotional 
manifestation.  Perhaps  permanent  disturbances  are  due  to  some 
mechanism  of  this  kind;  possibly,  under  the  influence  of  the  continued 
disturbance  of  an  emotional  origin,  trophic  phenomena  may  be  made  to 
appear.  Theoretically  this  is  possible,  and  in  practice  one  of  us  has 
had  the  opportunity  to  see  the  bullae  of  pemphigus  develop  without 
any  possible  intervention  of  simulation. 

At  all  events,  it  is  prudent  to  hold  one's  self  in  reserve  concerning 
the  setting  up  of  trophic  or  vasomotor  disturbances.  They  are  certainly 
much  less  frequent  than  was  formerly  believed,  but  it  would  perhaps 
be  extreme  to  deny  absolutely  the  possibility  of  their  existence. 

But  as  a  fact,  and  in  addition  to  the  three  examples  which  we  have 
quoted,  we  could  narrate  many  others.  There  do  exist  vasomotor  and 
secretory  disturbances  which  if  not  permanent  are  at  least  repeated  in 
the  course  of  psyehoneuroses,  and  this  in  an  unquestionable  manner, 
without  any  possibility  of  suggestion  or  simulation,  but  merely  by  the 
common  mechanism  of  emotional  action. 

3.  Phobic  Manifestations. — We  have  already  described  in  a  preced- 
ing chapter  a  certain  number  of  phobic  symptoms  which  focus  on  the 
skin.  We  now  wish  to  speak  of  that  numerous  class  of  patients  who 
are  afraid  that  they  have  contracted  syphilis  and  who  are  almost  un- 
interruptedly examining  their  skin.  Usually  these  phobic  symptoms 
spring  up  spontaneously  in  the  subject's  mind,  without  any  emotional 
phenomena,  as  a  resiilt  of  some  suspicious  sexual  relation.  Sometimes 
the  patient's  mind  becomes  fixed  on  his  skin  as  the  result  of  some 
slight  symptom,  such  as  balanitis,  herpes,  or  redness  due  to  various 
causes.  Sometimes  it  is  a  physician  who  is  responsible.  Having  a 
very  impressionable  and  suggestible  patient  to  treat,  and  not  taking 
into  consideration  this  peculiar  mental  quality,  he  may  have  said  to 
the  patient,  ''Now  keep  a  sharp  lookout,  examine  yourself,  and  come 
to  me  at  the  slightest  symptoms."  At  the  first  appearance  of  any 
redness,  or  a  pimple,  or  a  boil,  the  patient  is  greatly  alarmed.  The 
redness  is^  however,  often  caused  by  the  patient  himself,  who  has  brought 
it  about  by  continually  pulling  and  pinching  his  skin  while  examining 
it.  Sometimes  the  obsession  la^ts  for  a  long  time,  and  we  have  seen 
patients  who  for  years  after  a  dubious  coitus  were  still  examining  them- 
selves to  detect  possible  tertiary  symptoms,  for  they  had  been  carefully 
warned  that  the  secondary  symptoms  often  passed  unperceived. 


CUTANEOUS  FUNCTIONAL  SYMPTOMS.       107 

Under  other  circumstances  there  is  more  ground  for  the  obsession. 
There  are  patients  who  have  really  suffered  from  former  attacks  of 
syphilis,  or  who  have  been  afflicted  with  psoriasis,  or  eczema,  etc.,  and 
who  live  in  the  expectation  of  the  appearance  of  some  new  symptoms 
or  some  new  cutaneous  growth.  Hypochondriacs  they  certainly  are 
not,  phobies  or  obsessed  if  you  will,  but  their  phobias  and  obsessions 
are  the  accidents  of  extrinsic  suggestion. 

A  whole  series  of  other  phenomena  complicated  with  various  sug- 
gestive disturbances  may  result  from  the  psychic  diffusion  of  symptoms 
which  really  exist.  In  these  cases  the  patient  is  not  obsessed  about  his 
lesion,  but  about  his  symptoms,  and  chiefly  the  symptom  of  itching. 

One  frequently  sees  patients  who  have  a  trifling  itching  sore,  a 
slight  chafing  or  eczema  of  the  scrotum  or  armpits,  etc.,  whose  itching 
has  continually  spread  further  simply  by  psychic  fixation. 

Mr.  P.,  thirty-eight  years  of  age,  had  had  a  generalized  itching  for 
several  months,  which  had  become  so  intense  that  it  was  impossible 
for  him  to  sleep.  This  itching  obsession  hindered  the  patient  in  all  his 
affairs  and  he  was  obliged  to  give  up  his  work.  He  ceased  to  take 
sufficient  nourishment,  and  as  a  consequence  developed  a  very  serious 
neurasthenic  condition.  The  starting-point  of  the  psychic  diffusion  of 
this  phenomenon  consisted  in  a  slight  eczema  of  the  scrotum.  The  in- 
teresting thing,  but  one  frequently  observed,  is  that  before  having  this 
itching  the  patient  had  suffered  from  phobia  of  the  heart  for  eight  years 
as  a  result  of  a  mistaken  diagnosis,  but  from  the  day  that  his  attention 
became  directed  to  his  skin  he  never  gave  his  heart  another  thought. 

Moreover,  do  we  not  often  see  the  best-balanced  people  seized  with 
a  transitory  attack  of  itching  because  they  have  been  for  a  greater  or 
less  length  of  time  with  people  w^ho  had  the  itch  ?  The  desire  to  scratch 
is  contagious,  and  psychic  impression  is  enough  to  start  it  going.  Is 
not  this  a  very  typical  example  of  an  objective  mental  phenomenon? 
Although  in  the  majority  of  people  the  symptom  does  not  last,  we 
have  nevertheless  seen  people  in  whom  the  purely  suggestive  mani- 
festation took  such  firm  hold  that  they  got  to  the  point  where  they  were 
convinced  that  they  had  an  attack  of  the  itch,  or  of  pityriasis,  and  they 
would  spend  days,  even  weeks,  seeking  for  objective  symptoms.  In  view 
of  the  production  of  these  purely  subjective  phenomena  without  any 
other  cause  than  a  mental  representation,  one  can  understand  how 
easily  a  real  localized  pruritus  may  become  diffused  in  neuropaths. 

Under  the  influence  of  this  itching,  the  patient  feels  the  greatest 
desire  to  scratch,  and  the  slight  injuries  to  the  skin  caused  by  this 
scratching  may  become  gradually  spread  over  all  the  body,  in  parts 
that  have  nothing  to  do  with  the  real  lesion,  and  which  may  gradually 
establish  one  or  other  of  these  forms  of  real  prurigo  which  are  stiU  so 
little  known  in  dermatology,  and  which  undoubtedly  in  a  number  of 
cases  are  caused  by  a  purely  psychic  mechanism  analogous  to  that  which 
we  have  just  described. 


108  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

Phobic  phenomena  may  also  be  established  which  have  nothing  to 
do  with  the  skin,  but  are  due  to  changes  in  the  general  health  which 
may  cause  them  through  the  medium  of  the  skin, — the  phobia  of  cold  or 
of  heat,  or  the  fear  of  perspiring  too  freely,  or — ^what  is  so  frequently 
found  among  the  working  classes  who  are  afraid  of  driving-in  the  sweat 
— of  not  perspiring  enough.  All  this  may  be  the  starting-point  of  real 
education  of  the  skin  in  thermic  sensibility.  Patients  get  to  the  point 
where  they  suffer  at  the  slightest  change  of  temperature,  where  they 
are  always  too  hot  or  else  too  cold.  One  can  easily  picture  the  vari- 
ety of  troubles  which  may  be  created  in  this  way.  Under  the  influence 
of  the  emotional  state  into  which  the  patient  is  thrown  at  any  change 
of  temperature  which  he  must  undergo,  vasomotor  symptoms  may  be 
produced,  which  would  in  a  certain  measure — but  secondarily — justify 
the  impressions  felt  by  the  patient  and  become  the  starting-point  of  the 
most  pronounced  fixation. 

There  is  a  whole  class  of  neuropaths  who  are  terribly  afraid  of 
even  the  slightest  draught,  and  who  feel  one  even  when  it  does  not 
exist.  One  of  our  clients  who  used  to  have  this  phobia, — which,  how- 
ever, was  cured  a  long  time  ago, — ^tells  the  following  story  on  himself: 
**I  used  to  be  so  terribly  afraid  of  the  slightest  draught  that  I  would 
go  into  society  as  seldom  as  possible.  One  evening  in  a  drawing-room 
I  sat  down  before  a  closed  door,  and  scarcely  was  I  seated  when  I  was 
aware  of  cold  air  on  my  back.  I  changed  my  place  and  established 
myself  safely  in  a  corner.  At  the  end  of  the  evening,  I  wanted  before 
leaving  to  assure  myself  that  the  door  before  which  I  had  seated  myself 
at  first  was  not  tightly  shut.  I  went  up  to  it  and  looked  at  it,  and  then 
discovered  that  it  was  the  door  of  a  cabinet  built  into  the  wall." 

We  have  seen  very  many  such  people  with  educated  thermal  sensi- 
bility and  phobias  concerning  changes  of  temperature.  Naturally  the 
discomfort  that  they  feel  has  generally  been  considered  as  of  organic 
nature.  They  have  been  told  that  their  circulation  is  not  good,  that 
arthritism  was  one  of  the  pathogenic  factors  of  it.  All  methods  of 
treatment-T-massage,  douches,  and  medicines — have  naturally  followed, 
which,  when  practised  without  any  conception  of  re-education  and  with- 
out being  associated  with  psychotherapeutic  treatment,  have  only  suc- 
ceeded in  orienting  the  patient's  mentality  more  fixedly  and  increasing 
the  intensity  of  the  sjanptoms  which  he  felt. 


CHAPTER  VII. 

FUNCTIONAL  SYMPTOMS  IN  THE  NEURO-MUSCULAR  APPARATUS. 

We  shall  study,  in  this  chapter,  all  those  dynamic  or  static  muscular 
disturbances  which  may  be  observed  in  the  course  of  the  development 
of  the  psychoneuroses.  Among  these  numerous  and  complex  troubles, 
there  are  evidently  a  certain  number  in  the  production  of  which  other 
factors  than  the  neuro-muscular  apparatus  come  into  play.  Their  group- 
ing is  in  fact  merely  symptomatic  and  purely  schematic,  all  question 
of  pathogeny  and  mechanism  being  set  aside. 

First  of  all,  as  the  most  important  from  the  clinical  as  well  as  from 
the  theoretical  point  of  view,  we  shall  study  fatigue,  fatiguabihty, 
and  exhaustion,  with  their  functional  consequences,  or,  in  other  terms, 
physical  asthenia. 

In  a  later  paragraph  we  shall  take  up  disturbances  of  equilibrium 
and  coordination.  Then  there  will  be  another  class  of  wholly  disso- 
ciated facts — ^tremors,  choreas,  and  choreiform  movements — which  will 
demand  our  attention. 

Finally  we  shall  pass  in  rapid  review  paralyses  and  contractures. 

1.  Fatigue,  Fatiguability,  Exhaustion,  and  their  Functional  Con- 
sequences.— In  the  sensations  of  fatigue,  of  which  neurasthenics  so 
often  complain,  two  different  kinds  of  facts  must  be  studied.  These 
patients  have,  very  frequently  if  not  constantly,  the  impression  of  being 
fatigued  without  having  made  any  effort.  This  is  a  purely  suggestive 
impression.  On  the  other  hand,  they  are  truly  fatiguable  in  this  sense, 
that  any  real  physical  exertion  exhausts  them  more  or  less  rapidly. 

We  shall  pass  rapidly  over  the  impression  of  fatigue  itself.  It  may 
have  several  origins.  In  the  emaciated  neurasthenic  who  is  already 
more  or  less  exhausted,  it  is  easily  explained.  At  other  times,  and 
very  frequently,  it  is  a  simple  phenomenon  of  auto-suggestion,  a  memory 
of  fatiguability  which  has  already  been  experienced,  but  which  is  evoked 
more  or  less  continually,  if  one  might  so  put  it.  Under  other  circum- 
stances, it  is  a  question  of  a  sensation  which  may  be  experienced  by 
many  people,  quite  apart  from  any  neurasthenic  condition,  but  which 
is  reinforced  in  the  case  of  neurasthenics  by  the  elements  of  auto- 
suggestion. 

The  well-known  fatigue  on  waking,  in  particular,  which  one  finds 
in  nearly  all  arthritics,  only  becomes  a  neurasthenic  symptom  when 
the  person  is  obsessed  concerning  this  sensation.  It  is  the  obsession 
and  not  the  fatigue  which  is  unhealthy,  for  this  is  in  a  way  a  con- 
stitutional phenomenon  which  most  well-balanced  individuals  pay  no 
attention  to,  because  they  know  of  how  little  importance  it  is,  and  that 

109 


110  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

the  fatigue  which  they  feel  will  disappear  under  the  influence  of 
physical  or  mental  exercise. 

Fatiguability  on  making  any  effort  is  one  of  the  commonest  signs  which 
is  met  with  in  neurasthenia.  It  belongs,  one  might  almost  say,  peculiarly 
to  this  psychoneurosis.  It  explains  the  fact  that  the  patient  practically 
finds  it  impossible  to  make  any  physical  effort  without  very  quickly 
experiencing  more  or  less  intense  fatigue  and  more  or  less  complete 
exhaustion.  It  is  a  synonym  for  muscular  asthenia,  or  amyasthenia,  and, 
if  we  have  employed  the  word  fatiguability,  it  is  because  on  the  one 
hand  it  arouses  no  prejudice,  and  on  the  other  it  expresses  the  clinical 
fact  itself.  In  fact,  when  one  says  asthenia,  one  seems  to  indicate  by 
it  a  constant  diminution  of  muscular  energy.  Now,  although  there  is 
a  great  number — and,  to  tell  the  truth,  too  great  a  number — of  neuras- 
thenics who  hold  the  theory  of  the  impossibility  of  making  an  effort, 
there  are  others  who  are  capable  of  effort  and  of  considerable  physical 
work,  and  who  only  complain  of  the  impression  of  fatigue  as  coming 
not  too  quickly  but  being  too  strongly  felt.  How  many  times  we  have 
heard  these  patients  say,  ''I  do  it,  but  it  uses  me  up."  Let  us,  there- 
fore, preserve  the  old  word  fatiguability,  and  leave  the  term  asthenia 
to  those  who  maintain  the  organic  and  quasi-irreducible  nature  of  the 
disturbances  of  physical  energy  in  the  neurasthenic. 

Let  us  go  on  to  the  classic  clinical  characteristics  of  this  order 
of  symptoms.  They  may  be  very  briefly  summed  up.  We  may  say, 
as  do  all  authors,  that  the  neurasthenic  tires  more  rapidly  and  that  his 
fatigue  lasts  longer.  Let  us  add  that,  according  to  a  great  number  of 
observers,  the  neurasthenic  is  incapable  of  impulse  and  cannot  be  carried 
away  by  enthusiasm. 

The  neurasthenic  tires  very  rapidly.  This  means  that,  given  a  cer- 
tain constitution  for  an  individual  when  he  is  in  a  normal  condition  of 
health,  the  work  that  he  is  capable  of  may  be  rated  at  100,  but  when 
he  is  ill  the  work  of  which  he  is  capable  will  not  be  equal  to  more  than 
50,  20,  10,  or  even  less,  and  he  will  get  to  the  point  where  the  figure  1 
would,  in  the  case  of  certain  patients  to  whom  all  effort  is  impossible, 
still  be  too  high. 

The  fatigue  of  neurasthenics  is  very  lasting.  This  explains  another 
fact,  that,  while  in  normal  condition  the  length  of  time  equal  to  1  would 
be  enough  for  a  patient  to  rest  from  work  equal,  for  example,  to  10, 
a  neurasthenic  would  require  rest  equal  to  10  in  order  to  be  able  to  start 
in  again  upon  work  which  is  equal  to  1. 

The  rapidity  and  lasting  quality  of  fatigue  are  two  characteristics 
which  have  been  demonstrated  experimentally.  Ballet  and  Philippe, 
by  means  of  Mosso's  ergograph,  have  shown  that  in  a  neurasthenic  the 
power  of  muscular  contraction  is  exhausted  much  more  quickly  than  in 
a  healthy  man,  and  that  in  order  to  recover  this  power  the  time  which 
would  be  sufficient  for  a  normal  individual,  or  even  for  a  patient 
afflicted  with  muscular  atrophy,  would  be  too  short  for  the  neuropath. 


SYMPTOMS  IN  NEURO-MUSCULAR  APPARATUS.    Ill 

Let  us  add  at  once  that  Ballet  is  none  the  less  convinced  of  the  psychic 
nature,  in  the  greater  number  of  cases  at  least,  of  such  a  phenomenon. 

The  neurasthenic  is  incapable  of  progressive  endeavor.  This  has 
been  said  elsewhere,  but  it  is  Deschamps  principally  who  has  defended 
this  conception.  To  describe  this  impossibility  of  progressive  endeavor 
he  uses  the  neologism  '  '  aphoria.  '  '  To  quote  this  author,  '  '  The  asthenic, 
given  a  certain  fixed  quality  of  strength,  is  incapable  of  increasing 
his  capital  of  energy  by  exercise;"  and  further,  ''If  it  takes  a  patient 
five  or  ten  years  to  get  to  the  point  where  he  can  walk  five  minutes  more, 
one  can  hardly  call  that  progressive  endeavor;"  and  still  further,  ''He 
[the  asthenic]  passes  through  successive  degrees  of  strength;  these  are 
degrees  of  strength  which  endeavor  is  powerless  to  modify.  An  asthenic 
possesses  to-day  a  definite  capital  of  force;  this  capital  is  stable  for  the 
time  being,  and  always  yields  the  same  revenue.  To  work  beyond  that 
makes  him  bankrupt, — that  is  to  say,  it  brings  on  a  state  of  intoxication 
or  sharp  attack.  It  is  a  capital  which  cannot  be  changed  either  by 
progressive  endeavor  or  by  medicines.  It  is  necessary  for  the  whole 
organism  to  be  improved  and  transformed  by  the  efforts  of  nature, 
aided  by  wise  therapy,  in  order  to  place  it  on  a  little  higher  level.  On 
this  new  level,  he  would  possess  a  new  capital  of  strength  a  little 
above  that  of  the  preceding,  but  which  would  remain  the  same  for  a 
certain  length  of  time,  and  which  cannot  be  modified  by  the  impulse 
toward  improvement."  These  short  extracts  help  one  to  grasp 
Deschamps 's  conception.  This  author,  who,  moreover,  is  a  good  ob- 
server, is,  according  to  our  way  of  thinking,  wrong  in  not  pointing  out 
with  sufficient  exactness  to  which  special  class  of  patients  his  doctrine 
applies.  Prom  his  description,  it  would  seem  that  asthenia — his  asthenia, 
with  permanence  as  its  characteristic — forms  an  integral  part  of  the 
symptomatology  of  neurasthenia,  since  he  studies  it  side  by  side  with 
headache,  backache,  etc.  Under  these  conditions  we  are  very  far  from 
sharing  his  opinion,  which  latter  we  even  find  peculiarly  dangerous, 
because  it  is  peculiarly  discouraging.  Any  work  treating  of  neurasthenia 
is  almost  sure  to  be  read,  and  quite  too  often  in  any  case,  by  neuras- 
thenics, who — whether  asthenic  or  not — always  find  for  themselves 
sufficient  strength  to  read  such  books,  and  to  reread  them.  And  we 
have  seen  subjects,  imbued  with  the  doctrines  of  Deschamps,  who  were 
only  too  ready  to  become  crystallized,  "imbedded"  in  their  given 
position,  because  they  were  convinced  that  any  rapid  progress  was 
impossible. 

Let  us  add,  however,  that  it  is  very  true  that  one  does  meet,  in  the 
progressive  improvement  of  neurasthenics,  a  certain  number  of  diffi- 
culties which  we  must  take  into  consideration.  In  this  group  of  facts, 
as  well  as  in  those  met  with  in  the  course  of  the  psychoneuroses,  we 
have  to  interpret  the  rapidity  and  tenacity  of  fatigue  and  the  diffi- 
culties of  progressive  effort.  These  are  the  facts  which  are  commonly 
expressed  in  comparing  the  neurasthenic  to  an  electrical  machine  by 


112  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

saying  that  he  has  insufficient  potentiality,  and  that  his  accumulators 
are  charged  slowly  and  discharged  too  quickly,  etc. 

It  seems  to  us,  first  of  all,  necessary  to  study  phenomena  which  are 
both  physiological  and  psychological,  and  which  underlie  the  production 
of  fatigue  in  healthy  individuals. 

As  a  matter  of  fact,  the  human  motor  cannot  in  any  way  be 
compared  to  a  mechanical  motor.  Here,  for  example,  is  a  locomotive 
in  good  running  order.  Under  all  circumstances  it  would  be  able  with 
a  definite  amount  of  coal  to  produce  a  certain  amount  of  mechanical 
work,  a  work  which  may  be  translated  into  a  mathematical  formula. 
No  matter  what  the  circumstances  might  be,  it  could  do  neither  more 
nor  less. 

Here,  on  the  other  hand,  is  a  man  in  good  physical  health.  Under 
these  circumstances  he  would  be  capable  of  work  whose  value  could  be 
expressed  by  numbers  running,  for  example,  from  one  to  twenty.  The 
thing  that  limits  physical  work  in  a  man  is  not  lack  of  fuel,  it  is  not 
even  what  might  be  called  the  wear  and  tear  of  his  mechanism,  neither 
is  it  the  appearaiice  of  fatigue  which  limits  his  physical  activity.  He 
may,  as  a  matter  of  fact,  after  he  has  felt  his  first  sense  of  fatigue,  do 
work  of  even  a  superior  quantity  to  that  which  he  produced  in  the 
period  preceding  his  first  sensations  of  tire.  The  thing  that  definitely 
stops  his  physical  work,  as  also  intellectual  work,  is  an  extremely  com- 
plex phenomenon  known  as  exhaustion.  What  we  must  first  try  to 
explain  is  how  this  exhaustion  may  be  produced  more  or  less  rapidly, 
according  to  circumstances  and  to  individuals. 

All  physical  work  from  its  start  falls  into  four  periods, — ^namely, 
getting  started,  automatic  work,  voluntary  w^ork,  exhaustion. 

First  of  all,  what  is  automatic  work?  It  only  exists  where  there  is 
an  accustomed  physical  activity.  An  employé,  for  example,  automat- 
ically and  mechanically  traverses  the  distance,  whether  it  be  long  or 
short,  which  separates  him  from  his  office.  A  workman  can  ply  his 
trade  for  many  hours  without,  as  it  were,  taking  any  notice  of  it:  the 
work  in  this  case  wall  be  in  a  sort  of  a  way  instinctive,  and  will  obey 
to  a  certain  degree  purely  mechanical  laws.  This  automatic  work 
reaches  its  limit  at  the  first  appearance  of  a  feeling  of  tire.  Apart  from 
any  external  phenomena  it  may  occur  more  or  less  rapidly  according 
to  the  degree  of  enthusiasm  which  the  individual  feels.  This  enthusiasm 
is  nothing  more  than  the  progressive  adaptation  of  an  individual  to  a 
definite  piece  of  work.  If  such  adaptation  is  perfect,  it  cannot  help 
but  increase  the  possible  daily  quantity  of  automatic  work,  and  the 
latter  is  increased  not  only  because  the  motor  is  in  some  way  rendered 
more  powerful  by  the  enthusiasm,  but  also  because  the  force  produced 
is  better  utilized  and  is  fully  concentrated  on  the  desired  end.  A  man 
with  this  progressive  sense  of  work  possesses  a  better  lever  and  he  uses 
it  better  if,  instinctively,  without  either  will  or  reflection,  he  can  use 
it  automatically  as  well  as  intelligently.    Let  us  repeat,  then,  that  two 


SYMPTOMS  IN  NEURO-MUSCULAR  APPARATUS.         113 

elements  enter  into  the  expression  of  the  enthusiastic  human  motor, — 
increase  of  production  of  force  and  also  (we  might  almost  say  chiefly) 
a  better  adaptation,  or,  if  one  prefers  it,  a  higher  degree  of  harmony 
in  the  effort. 

This  amounts  to  saying  that,  apart  from  any  question  of  enthusiasm, 
harmonious  effort  is  always  less  fatiguing  than  badly  applied  effort, 
because  in  the  latter  case,  for  the  same  quantity  of  work  produced,  there 
must  be  a  more  or  less  considerable  useless  expenditure  of  strength. 
This  is  exactly  what  makes  the  difference  between  a  good  and  a  poor 
worker.  The  latter,  because  he  does  not  know  how  to  use  his  tools, 
will  be  much  more  apt  than  the  other  to  feel  the  first  sensation  of  tire. 

This  must  necessarily  be  so,  and  largely  because  the  first  idea  of 
w^eariness,  even  the  accumulated  impressions  of  fatigue,  put  a  decided 
limit  upon  human  work.  One  says  of  people,  that  they  have  energy, 
which  means  that,  along  with  their  margin  of  automatic  physical  work, 
they  have  a  large  margin  of  voluntary  work.  During  this  second 
period,  and  this  is  the  classical  expression,  the  man  struggles  against 
the  animal  in  him;  thus  one  sometimes  sees  frail  people  capable  of 
miracles  of  energy.  History  furnishes  numerous  examples  of  this.  It 
is  none  the  less  true  that  human  energy  has  its  limitations,  and  that 
there  comes  a  moment  when  the  will  itself  is  incapable  of  under- 
taking any  supplementary  effort.    The  man  is  then  exhausted. 

Under  other  circumstances,  it  does  not  work  in  this  way,  and  it 
seems  that  under  certain  given  conditions  the  margin  of  automatic 
effort  may  increase  almost  indefinitely. 

Under  the  influence  of  great  emotions,  or  in  the  course  of  patho- 
logical conditions  such  as  ambulatory  automatism,  or  certain  forms  of 
cerebral  excitement,  à  man  does  not  struggle  against  fatigue,  he  no 
longer  feels  it  nor  perceives  it,  because  his  mentahty  is  asleep,  as  it 
were,  or  because  he  has  become  monoideastic.  All  the  physical  and 
intellectual  impressions  other  than  those  which  have  to  do  with  the 
end  he  is  interested  in  are,  we  might  say,  inhibited  in  him. 

This  fact  is  of  great  importance  to  us,  because  it  shows  how  much 
distraction  (the  word  distraction  being  taken  in  its  etymological  sense) 
facilitates  effort,  and  because  it  also  explains  how,  inversely,  attention 
makes  the  effort  difficult. 

Here  is  where  the  manner  of  getting  started  counts.  If  one,  as  a 
matter  of  fact,  begins  any  work  with  a  feeling  of  disgust  or  anxiety  or 
the  conviction  that  it  will  not  go  on  well,  this  work  will  soon  become 
fatiguing,  because  a  mental  element  has  been  added  to  it  at  the  start, 
because  the  effort,  instead  of  being  automatic  will  be  in  some  sense 
voluntary,  and  because  being  voluntary  it  must  necessarily  not  be  so 
perfectly  adapted. 

It  is  a  common  thing  to  say  that  one  struggles  against  fatigue. 
This  phrase  expresses  not  only  a  phenomenon  of  the  will,  but  also 
a  physical  fact.  The  gait  of  a  tired  man,  if  his  fatigue  has  come 
8 


114  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

from  a  walk  less  long  than  that  for  which  he  was  prepared,  is  a  stiff 
walk  if  useless  effort  is  expended.  It  follows  very  clearly  from  this 
that  under  these  conditions  fatigue  will  be  rapid.  A  few  examples  will 
make  our  idea  clear.  Here  are  troops  on  the  march.  At  the  end  of 
the  column  are  a  certain  number  of  laggards.  Among  them  some  are 
limping,  but  there  are  also  a  certain  number  of  strong,  hearty  fellows, 
good  country  specimens,  who  are  used  to  walking  long  distances  and 
to  hard  work  on  the  soil.  These  men  have  hundreds  of  times  done 
much  harder  physical  work  than  that  which  is  demanded  of  them  now. 
They  have  by  no  means  come  to  the  limit  of  their  endurance.  But 
to-day  they  have  lost  heart.  They  are  disgusted  with  their  calling. 
They  have  been  homesick  ever  since  they  got  up.  During  the  whole 
time  of  their  march  they  have  been  complaining  about  their  hard  lot; 
and  here  we  see  them  lagging  along,  limping,  dragging  their  feet,  and 
all  tired  out,  with  the  perspiration  running  off  their  faces.  Let  an 
officer  come  along  who  can  brace  up  their  courage,  or  let  the  music 
start  up  some  air  from  home,  and  they  will  quicken  their  step,  and 
later  reach  their  halting  place  without  a  shadow  of  fatigue,  without 
having  felt  the  slightest  need  of  putting  forth  any  real  energy.  But, 
on  the  contrary,  let  them  keep  up  their  slow  lagging  walk  for  a  few 
miles  further,  and  they  will  drop  by  the  way,  overcome,  used  up,  and 
exhausted. 

Here  are  other  examples.  A  runner  and  a  bicyclist  are  in  fine 
condition.  A  few  days  before  one  could  have  accomplished,  without 
any  sign  of  fatigue,  eighteen  to  twenty-four  and  the  other  from  ninety 
to  one  hundred  and  twenty  miles.  Let  them,  at  the  end  of  a  few 
miles,  however,  begin  to  fear  that  they  are  not  sure  of  the  way,  and 
they  will  find  themselves  exhausted  long  before  they  have  accomplished 
the  eighteen  or  the  ninety  miles.  Why?  Because  their  effort,  instead 
of  being  automatic,  will  become  conscious,  and  therefore  less  thoroughly 
adapted  and  more  fatiguing.  It  is  identically  the  same  phenomenon 
which  we  have  just  seen  in  the  case  of  the  soldiers. 

When  an  individual  reaches  his  resting  place  after  a  long  walk,  he 
will  feel  more  or  less  fatigued.  The  next  day,  on  waking,  he  will  find 
himself  very  stiff.  If  he  stays  in  bed,  he  will  feel  the  same  fatigue 
for  several  days.  If,  on  the  other  hand,  he  takes  up  his  journey,  he 
will  often  be  able  to  finish  it  less  fatigued,  as  far  as  his  subjective 
impressions  go,  than  he  was  at  the  start.  The  neurasthenic  behaves 
in  the  same  way,  the  question  of  degree  and  the  moment  that  sensations 
appear  being  put  aside.  And  if  under  the  impression  of  fatigue  he 
stops  more  or  less  absolutely,  he  will  often  retain  this  impression  of 
fatigue  for  a  much  longer  time  than  if  he  got  back  to  work.  It  is  by  a 
mechanism  of  this  kind  that  one  explains  in  a  purely  subjective  way 
the  prolongation  of  impressions  of  fatigue  in  the  neurasthenic.  If  his 
fatigue  lasts,  it  is  because  he  does  not  take  up  his  work  again. 

In  fine,  the  conclusion  at  which  we  wish  to  arrive,  and  which  the 


SYMPTOMS  IN  NEURO-MUSCULAR  APPARATUS.         115 

facts  seem  to  justify,  is  that  exhaustion  is  only  partially  an  organic 
phenomenon.  Its  rapidity  is  directly  proportioned  to  the  degree  of  con- 
sciousness in  the  effort.  It  is  inversely  proportioned  to  the  degree  of 
automatism  in  the  effort  put  forth  and  to  the  energetic  qualities  of  the 
person  who  is  working. 

All  of  this  helps  us  very  much  to  understand  the  peculiar  nature  of 
this  rapid  and  easily  acquired  exhaustion  of  which  so  many  neurasthenics 
complain.  These  patients  really  do  not  know  what  it  is  to  feel  that 
good  healthy  tire  which  is  almost  pleasant  and  comforting,  because, 
from  the  moral  point  of  view,  it  represents  work  accomplished.  They 
only  know  that  exhaustion  which  sometimes  comes  too  soon  and  rapidly 
gTOws  worse,  and  which,  on  the  contrary,  sometimes  strikes  them  like 
a  thunderbolt,  but  does  not  surprise  them.  These  feelings  are  accom- 
panied by  various  symptoms  of  anxiety,  shortness  of  breath,  emotional 
phenomena  of  every  kind,  accompanied  or  not  by  phobic  symptoms. 
Such  patients  finally  become  very  much  limited  in  their  physical 
activity;  some  cannot  walk  a  hundred  yards,  others  fancy  that  they 
cannot  go  down  stairs.  There  are  some  who  stay  in  their  rooms,  some 
even  who  never  leave  their  beds;  sometimes  it  is  really  true  that  the 
slightest  effort  plunges  them  into  all  those  disagreeable  sensations  which 
we  have  just  described.  Sometimes,  howe-ver,  they  are  merely  phobies 
in  whom  the  fear  of  exhaustion  inhibits  all  desire  to  make  any  effort. 

This  exhaustion  does  not,  however,  necessarily  extend  to  all  forms 
of  physical  activity.  One  person  will  be  exhausted  by  standing,  but 
can  endure  walking  or  long  conversations.  Another  cannot  walk  for  a 
greater  or  less  length  of  time  after  his  meals,  because  he  holds  that 
the  work  of  walking  combined  with  the  work  of  digestion  is  too  much 
for  him.  Still  another  finds  that  he  is  incapable  of  any  effort  whatsoever 
unless  he  has  slept  a  given  number  of  hours.  ''When  I  have  spent  ten 
hours  in  bed  and  slept  nine  of  them,"  a  patient  said  to  us,  "then  I 
can  do  things.  If  I  have  only  been  in  bed  for  nine  hours  and  slept 
eight,  I  am  incapable  of  doing  anything.  '  '  The  most  subtle  distinctions, 
and  the  most  varied  associations  in  the  domain  of  things  possible  and 
impossible,  are  likely  to  turn  up  in  this  connection. 

One  peculiar  feature  in  the  exhaustion  of  neurasthenics  is  the  sudden 
appearance,  without  any  warning,  of  intense  fatigue  which  obliges  the 
patient  to  stop  at  once.  To  phenomena  of  this  kind  there  has  been 
given  the  classic  term,  which  is  somewhat  abused,  of  neurasthenical 
paraplegia. 

Yery  often  this  phenomenon  has  a  peculiar  origin.  It  occurs  in 
patients  who,  for  one  reason  or  another,  have  momentarily  forgotten 
that  they  belong  to  the  class  who  are  so  easily  exhausted.  Then,  by  the 
common  association  of  some  idea,  they  suddenly  remember  their  con- 
dition, and  experience,  as  it  were  psychically,  the  sum  total  of  all  the 
fatigue  that  they  ought  to  have  felt.  Phobic  symptoms  then  come  into 
play.     They  are  afraid  that  they  are  going  to  be  used  up.     They  are 


116  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

afraid  that  they  cannot  go  any  further,  and  they  stop  short  without 
strength  and  without  energy.  These  are  the  same  patients  who,  when 
you  try  to  explain  the  mechanism  of  their  fatigue  to  them,  will  say 
to  you,  ''But,  doctor,  you  must  see  that  my  fatigue  was  real,  because 
it  overcame  me  when  I  was  not  thinking  of  it  at  all.  '  '  Really  they  did 
not  think  of  it  before  they  experienced  it,  but  they  felt  it  because  it 
was  borne  in  upon  them  to  think  about  it. 

Here,  if  you  like,  is  a  typical  example  of  such  a  case.  One  of  us 
one  day  had  occasion  to  examine  a  lady  who  was  very  neurasthenic  and 
profoundly  ''asthenic."  She  said  it  was  impossible  for  her  to  sit  up 
for  more  than  a  few  minutes,  or  to  hold  out  her  arm  for  the  shortest 
time.  When  we  examined  her,  her  arm  did  as  a  fact  fall  weakly  after  it 
had  been  extended  two  or  three  seconds.  The  continuation  of  the  ex- 
amination revealed  that  hypersesthesia  of  the  scalp  which  is  common 
among  so  many  nervous  people  who  are  nevertheless  not  true  neuro- 
paths. This  patient  had  a  magnificent  head  of  hair,  very  elaborately 
dressed.  On  remarking  that  on  account  of  her  hyperaesthesia  she  must 
find  it  very  difficult  to  let  anybody  arrange  her  hair,  "Oh,  doctor," 
said  she,  "I  would  never  allow  anybody  to  touch  my  hair.  I  do  it 
myself.  '  '  This  patient,  who  was  not  able  to  hold  her  arm  stretched  out 
for  three  seconds,  could  hold  her  two  hands  above  her  head  an  hour 
a  day  to  arrange  her  hair  and  brush  it  at  night.  It  is  quite  true  that 
she  had  not  given  this  matter  a  thought. 

Furthermore,  this  physical  asthenia  of  neurasthenics  is  essentially 
variable  at  different  times.  One  such  unfortunate  was  so  profoundly 
afflicted  that  he  believed  that  he  could  not  walk  for  more  than  five 
minutes  without  being  exhausted.  But  we  were  able  while  talking  about 
his  troubles  to  keep  him  walking  up  and  down  for  an  hour  and  a 
quarter,  without  his  ever  noticing  it. 

It  is  evident  that  this  neurasthenic  asthenia  strongly  resembles 
symptoms  of  the  same  kind  which  are  met  with  in  a  convalescent.  The 
latter,  it  is  true,  is  capable  of  only  such  special  effort  as  is  suitable 
to  his  physical  condition  at  the  moment.  In  his  case  all  his  physical 
activities  are  simultaneously  attacked.  In  the  former,  on  the  other 
hand,  who  is  illogical,  variable,  and  incoherent,  asthenia  is  a  sjonptom 
of  purely  psychic  origin  and  of  accessory  physical  origin. 

We  might  add  that  its  physical  origin  is  mostly  accessory,  for  two 
reasons:  first,  because  in  some  slight  degree  there  may  come  in  some 
symptoms  in  the  production  of  exhaustion  in  a  neurasthenic  which, 
although  of  psychic  origin,  nevertheless  play  the  physical  rôle  to  some 
degree;  and,  then,  because  true  physical  asthenias  do  exist  in  certain 
cases. 

Sometimes,  in  fact,  the  neurasthenic  is  really  tired.  This  is  what 
we  will  call,  if  we  wish  to  use  the  expression,  a  neurasthenic  who  has 
"arrived."  Emaciated  and  weakened  by  lack  of  nourishment,  because 
he  has  suffered  from  those  disturbances  of  appetite  and  digestion  which 


SYMPTOMS  IN  NEURO-MUSCULAR  APPARATUS.        117 

we  have  long  since  described,  and  because  he  does  not  eat  enough,  he 
cannot  walk,  because  his  motor  apparatus  is  in  such  bad  condition  and 
because  he  is  so  poorly  fed. 

His  asthenia  is  thus  the  most  natural  thing  in  the  world.  But  it 
is  nevertheless  a  superadded  and  purely  secondary  symptom  which  has 
nothing  to  do  with  the  fatiguability  which  many  authors  hold  to  be 
essential. 

What,  then,  is  the  mechanism  of  the  phenomena  of  exhaustion  which 
one  finds  in  a  neurasthenic  ?  How,  in  other  words,  jioes  it  happen  that 
his  effort  is  cut  short  so  quickly?  This  is  the  question  which  we  have 
to  solve.  We  shall  explain  at  the  same  time  the  mechanism  of  non- 
inhibited  expressions  of  fatigue  concerning  effort  which  one  meets  in 
certain  patients. 

Dubois,  of  Berne,  attributes  fatigue  '  '  to  a  conviction  of  helplessness, 
following  a  real  sensation,  and  exaggerated  by  the  pessimistic  state  of 
mind  which  the  fatigue  itself  brings  on,  acting  on  our  morale."  ^'One 
ought  not  to  call  it  fatigue  when  there  has  been  no  work  performed," 
says  this  author;  that  is  to  say,  in  fact,  that  these  fatigued  patients 
belong  to  the  list  of  '  '  interposed  symptoms  '  '  who,  according  to  Dubois 's 
theory,  interpose  a  false  idea  into  the  reflex  arc.  This  conception  of 
Dubois's  seems  to  me  only  permissible  for  patients  who  feel  fatigued 
when  in  bed.  And  it  is  chiefly  to  them  that  his  interpretation  applies. 
Dubois,  who  elsewhere  is  such  a  strong  upholder  of  the  psychic  nature 
of  the  symptoms  experienced  by  neurasthenics,  does  not  think  but 
that  the  true  neurasthenic  may  also  suffer  from  true  fatigue. 

As  a  matter  of  fact,  one  sees  neurasthenics  who  have  been  in  bed 
for  some  weeks,  who  feel  themselves  incapable — on  account  of  fatigue, 
so  they  say — of  efforts  which  they  do  not  even  attempt.  Such,  from 
all  evidence,  are  pure  psychopaths,  more  or  less  abulic,  whose  men- 
tality has  become  crystallized  on  the  memory  of  some  former  fatigue 
that  really  did  occur.  Sometimes,  also,  they  suffer  from  real  fatigue 
by  reason  of  insufficient  nourishment.  But  such  cases  do  not  apply  to 
our  subject.  We  must  say  that  neurasthenics  are  very  rarely  also  abulic, 
as  is  apt  to  be  said  of  them.  There  are  some  who,  in  struggling  against 
their  affliction  and  their  sensations,  waste  a  store  of  energy.  If  there 
are  some  who  are  incapable  of  any  will  power,  there  are  also  some 
who  put  forth  all  the  will  power  that  they  once  were  able  to  exert.  We 
have  seen  these  patients  to  whom  some  physical  task  had  been  given. 
"If  you  wish  it,  doctor,"  they  would  say,  ''I  will  do  it;"  and  these 
patients  would  make  the  effort  that  was  asked  of  them,  such  as  running 
a  fixed  distance.  They  would  arrive  at  their  destination,  but  wholly 
exhausted.  Yet,  nevertheless,  the  effort  that  was  proposed  was  by  no 
means  excessive.  What  is  the  mechanism  of  this  phenomenon?  Accord- 
ing to  our  feeling,  if  these  patients  willed  well  they  did  not  know  how 
to  will;  they  willed  badly.  With  the  best  intentions  in  the  world  they 
would  never  succeed  in  overcoming  their  difficulties.    But  this  is  what 


118  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

these  patients  attempt  to  dt).  It  is  true  that  they  themselves  have 
raised  their  own  barriers.    We  must  explain  ourselves. 

The  first  and  by  no  means  the  least  important  fact  comes  from 
the  mentality  of  the  neurasthenic.  He  looks  upon  nothing  with  in- 
difference. Every  act  of  his  physical  life,  as  well  as  his  intellectual 
life,  is  counted,  meditated,  observed,  and  preserved  in  a  reminiscent 
condition  which  is  more  or  less  continually  present.  If,  therefore,  one 
asks  such  a  patient  to  make  a  physical  effort  in  which  he  may  or  may 
not  at  some  previous  time  have  had  feelings  of  fatigue,  instead  of 
getting  to  work  at  it  in  a  perfectly  simple  manner,  as  would  a  healthy 
individual,  he  is  going  to  watch  himself  while  he  does  it.  Sometimes  a 
memory  of  fatigue  will  come  to  him,  and  will  appear  again  in  the 
production  of  consecutive  impressions.  But  this  mechanism  is  neither 
constant  nor  necessary.  The  very  attention  which  the  patient  brings 
to  bear  upon  the  effort  that  he  is  making  is  sufficient  to  disturb  the 
action  which  he  wishes  to  perform,  because,  from  that  time  on,  instead 
of  being  automatic,  his  effort  becomes  voluntary  and  insufficiently 
adapted. 

One  has  only  to  watch  these  patients  somewhat  attentively  in  order 
to  realize  this  fact.  In  walking,  for  example,  there  is  nothing  normal 
in  the  way  in  which  they  behave.  Sometimes,  anxious  to  know  if  they 
will  be  able  to  keep  up  till  the  end,  they  begin  to  walk  as  fast  as  possible 
without  sparing  their  breath.  Soon  they  begin  to  pant,  and  it  is  not 
physical  fatigue,  properly  speaking,  which  is  going  to  make  them  stop, 
but  the  difficulty  which  they  will  find  in  getting  their  breath.  And  very 
often,  as  a  matter  of  fact,  it  is  this  extremely  unpleasant  sensation 
which  such  patients  describe  to  us  under  the  name  of  exhaustion. 

Sometimes,  on  the  other  hand,  they  will  begin  to  walk  more  slowly; 
they  count  their  steps,  as  it  were,  asking  themselves,  at  each  step,  if 
they  will  not  fall  exhausted  before  the  next  one.  We  have  already 
seen  how  greatly  the  respiratory  functions  may  be  modified  by  atten- 
tion, and  how  the  attention  to  a  certain  degree  inhibits  the  respiratory 
automatism.  Just  in  the  same  way  in  the  case  of  these  patients,  they 
may  be  obliged  to  stop  on  account  of  their  respiration.  Other  phenomena 
are  very  apt  to  occur.  In  fact,  in  the  normal  condition  in  all  the 
customary  forms  of  physical  activity  the  work  that  is  willed  follows 
automatic  work.  Our  patient,  attentive  to  his  promenade,  acts  from 
the  first  as  one  who  is  greatly  fatigued.  He  is  continually  causing  an. 
error  of  interpretation,  and,  by  bringing  his  will  into  play,  he  has  a 
psychological  impression  of  blocking  and  is  already  fatigued.  The 
application  of  his  will,  or  of  attention,  which  is  only  a  form  of  will, 
is  interpreted  by  a  real  return  shock  as  a  sensation  of  fatigue.  There- 
fore, one  of  two  things  occurs  :  on  the  one  hand,  our  patient,  for  reasons 
that  we  shall  determine  further  on,  is  abulic,  and  he  will  almost 
immediately  cease  to  make  any  effort,  or,  on  the  contrary,  being  very 
desirous  to  improve  and  to  progress  from  the  physical  point  of  view,  he 


SYMPTOMS  IN  NEURO-MUSCULAR  APPARATUS.    119 

will  push  himself,  and  then  there  will  appear,  as  a  result  of  his  ex- 
hausted condition,  or  the  feeling  of  stiffness  which  this  patient  will 
begin  to  experience,  a  whole  new  series  of  phenomena.  Psychic  tension 
has  its  physical  and  reciprocal  reaction.  This  is  a  well-known  fact. 
When  one  is  striving  toward  an  end,  he  puts  forth  every  moral  and 
physical  effort  of  his  whole  being.  One  holds  oneself  tense  while  making 
any  intellectual  effort.  Gesticulation  and  mimicry  are  only  the  classical 
expressions  of  this  general  law.  Our  patient,  therefore,  is  going  to 
stiffen  up  and  draw  himself  together.  His  gait  will  consequently  lose 
its  freedom.  Sooner  or  later  he  will  be  taken  with  pains  in  the  back 
and  cramps  in  the  legs,  and  these  sensations  will  be  produced  more 
quickly  than  formerly,  or  else  a  topalgia,  probably  lumbar,  will  soon 
occur.  Our  patient  is  from  now  on  rather  like  an  individual  trying  to 
walk  with  lumbago  or  an  arthropathy.  It  is  easy  to  see  that  under 
these  conditions  he  will  not  go  very  far. 

What  we  have  said  about  walking  we  could  repeat  exactly  for  any 
manifestation  of  physical  activity  whatsoever  when  attempted  by  a 
neurasthenic,  whether  his  general  condition  is  affected  or  not. 

On  the  other  hand,  one  can  see  very  easily  how  being  convinced  of 
a  difficulty  or  one's  own  helplessness  may  inhibit  effort.  Here,  for 
example,  is  an  individual  who,  in  a  moment  of  enthusiasm,  has  leaped 
over  a  rather  wide  ditch.  He  comes  back,  computes  the  width  of  the 
ditch,  and  thinks  he  was  very  fortunate  to  have  been  able  to  jump 
across.  Try  to  make  him  leap  over  this  ditch  once  he  knows  how 
wide  it  is,  and  nine  times  out  of  ten  he  will  fail  in  the  attempt,  or  if 
he  succeeds,  in  overcoming  he  will  have  had  to  put  forth  every  effort, 
and  when  he  reaches  the  other  side  he  will  sink  down  all  out  of  breath. 

Is  this  a  case,  properly  speaking,  of  a  moral  phenomenon?  It  is 
simply  a  case  of  the  intervention  of  psychic  phenomena  which  are 
focussed  upon  an  act  which,  to  be  performed  under  the  most  favorable 
conditions,  ought  to  be  in  some  degree  automatic.  It  is  no  less  true 
that  it  is  in  this  way  that  the  asthenia  of  a  neurasthenic  is  encouraged 
and  cultivated,  an  asthenia  which  serves  to  reinforce  the  memory  of 
previous  exhaustions.  In  the  same  way  the  automatic  part  which  may 
exist,  although  it  is  more  often  very  feeble,  is  still  further  reduced. 

This,  we  think,  explains  very  clearly  why  the  neurasthenic  cannot 
be  worked  up  to  further  effort.  He  knows  that  he  can  walk  without 
fatigue  for  five  or  ten  minutes,  or  even  an  hour.  During  this  time  his 
effort  will  be  normal,  automatic,  and  unconscious.  But  the  moment  that 
he  has  passed  what  he  considers  to  be  the  limit  of  his  endeavor,  the 
phenomena  which  we  have  just  described  will  come  into  play.  Unless 
he  has  had  appropriate  treatment,  it  is  plain  that  the  exhaustion  will 
always  come  on  at  the  same  time.  And  this  is  why  the  neurasthenic 
cannot  be  incited  to  endeavor. 

Here  is  a  demonstration  of  this  statement.  Two  patients  came  to  us 
the  same  day;  both  were  neurasthenics  and  incapable  of  long  effort. 


120  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

To  each  of  them  we  ordered  very  progressive  effort.  During  the  first 
days  their  effort  was  without  result.  Our  two  patients,  living  at  the 
same  hotel,  became  acquainted  with  each  other.  They  discovered,  out- 
side of  the  pale  of  their  diseases,  mutual  sympathies  and  the  same 
interests  and  tastes.  They  decided  to  go  into  training  together.  From 
that  time  on,  it  began  to  come  of  itself,  and  in  a  few  days  the  progress 
made  was  considerable,  enough  to  convince  the  patients  that  they  were 
gaining.  What  had  happened?  Following  the  advice  which  had  been 
given  them,  they  had  been  careful  not  to  speak  about  their  illness,  but, 
talking  of  various  things  which  offered  them  distraction,  thej^  were 
enabled  to  make  constantly  increasing  efforts  without  any  difficulty. 

As  to  the  relapses,  under  the  influence  of  training,  of  which 
Deschamps  speaks,  we  have  never  seen  any.  The  whole  reason  lies  in 
the  fact  that  the  patient,  in  the  course  of  his  exercises,  is  never  allowed 
to  get  to  the  point  of  exhaustion.  This,  as  we  shall  see  later,  is  a  simple 
matter  of  supervision. 

To  sum  up,  we  will  say  that  there  are  two  forms  of  asthenia  in 
the  neurasthenic.  One  has  to  do  only  with  the  symptoms  of  fatiguability. 
It  is  that  of  the  abulic  neurasthenic,  who  stops  the  first  moment  that  he 
feels  the  slightest  sensation  of  fatigue.  The  other  may  continue  to  the 
point  of  exhaustion;  he  is  the  neurasthenic  who  is  still  endowed  with 
energy.  In  one  case  as  in  the  other  the  automatic  work  is  very  largely 
suppressed.  In  the  second  case  alone  there  come  in  what  we  might  call 
disharmonies,  which  rapidly  create  a  peculiar  fatigue. 

It  goes  without  saying  that  these  disharmonies  do  not  necessarily  and 
inevitably  lead  to  exhaustion.  This  is  the  case  with  patients — generally, 
however,  those  who  are  mildly  affected — who  may  go  beyond  their  first 
feeling  of  fatigue  without  being  exhausted  by  doing  so.  These  are  those 
to  whom  we  alluded  above  who  say,  "I  do  it,  but  it  uses  me  up."  In 
their  case,  we  must  add,  the  psychologic  factors  of  distraction  come  into 
play.  These  are  they  who,  not  being  strongly  obsessed,  still  have  a 
taste  for  their  work,  during  which  they  forget  from  one  time  to  another 
that  they  are  sick.  This  is  the  reason  why  complete  exhaustion  may  be 
indefinitely  put  off.  But  that  is  not  enough  to  prevent  their  feeling 
fatigue  which  is  much  greater  than  under  normal  conditions  and  which 
is  also  very  effective. 

Does  this  mean  that  we  consider  that,  outside  of  the  psychophysical 
mechanism  which  we  have  just  set  forth,  the  neurasthenic  may  always 
be  capable  of  the  same  effort  which  he  could  make  when  he  was  well? 
Certainly  not,  and  we  do  not  attempt  to  deny  that  in  certain  patients 
there  is  a  very  real  fatigue.  But  to  what  does  it  respond  ?  Not  certainly 
to  a  real  physical  inferiority,  but  rather  to  the  mental  condition  of  the 
subject.  The  human  organism,  from  the  point  of  view  of  fatigue,  cannot 
be  dissected  into  parts.  There  is  not  one  physical  being,  another  moral 
being,  and  another  intellectual  being  separated  by  impassable  barriers. 
We  all  know  the  physical  fatigue  which  comes  from  emotion,  préoccupa- 


SYMPTOMS  IN  NEURO-MUSCULAE  APPAEATUS.    121 

tion,  or  intellectual  work.  We  come  away  from  a  long  discussion,  or 
some  slightly  arduous  task,  worn  out  in  body.  The  regular  quantity  of 
daily  work  that  one  can  dispose  of  represents  the  sum  of  physical, 
intellectual,  or  moral  effort.  And  what  happens'  in  the  case  of  the 
neurasthenic?  The  things  that  can  create  and  do  create  in  him  the 
effect  of  legitimate  fatigue  are  all  those  obsessive  preoccupations  of 
which  the  mentality  is  the  seat.  These  are  the  facts  which  we  shall 
take  up  later,  when  we  shall  attempt,  by  the  aid  of  the  data  furnished 
us  by  psychoanalysis,  to  make  up  the  synthesis  of  the  neurasthenic. 

However  this  may  be,  and  as  far  as  the  true  primary  asthenias  are 
concerned,  frankly  speaking  we  have  never  met  them,  except  under  very 
special  circumstances,  and  in  patients  who  in  other  ways  show  signs  of 
constitutional  mental  degeneracy, — i.e.,  the  phenomena  of  psychasthenia 
of  Janet,  which,  according  to  many  psychiatrists,  bears  a  close  relation 
to  a  periodic  psychosis.  In  the  latter,  certainly  we  find  associated  with 
mental  and  moral  deficiencies  physical  deficiencies  which  ar^^^almost  as 
difficult  to  remedy  as  it  is  to  change  their  psychic  defects.  Therefore, 
we  must  say  again  that  even  in  these  latter  the  asthenic  manifestations 
are  variable. 

There  are  also  (it  is  a  question  of  diagnosis)  individuals  who  have 
become  prematurely  aged,  who  are,  if  you  will,  asthenic,  but  in  whom  it 
is  a  question,  taking  it  all  in  all,  of  a  process  of  sfenile  involution  which 
is  only  abnormal  from  the  point  of  view  of  the  time  at  which  it  has 
occurred. 

As  in  the  neurasthenic,  he  may  show  signs  of  false  fatigue,  due  to 
error  in  mental  representation,  premature  fatigue,  by  reason  of  having 
entirely  suppressed  the  automatic  period  of  his  effort,  and  true  fatigue 
resulting  from  the  lack  of  nutrition  caused  not  only  by  his  obsessions 
and  preoccupations,  but  brought  on  more  often  by  disharmony  of  effort. 
In  the  neurasthenic  who  is  under  careful  direction  this  fatigue  is  the 
commonest  of  his  symptoms;  it  is  also,  according  to  our  opinion,  the 
one  which  yields  most  easily  to  appropriate  therapy.  This  idea  seems 
to  us  of  the  utmost  importance,  for  it  is  very  much  more  encouraging  to 
patients  than  that  which  takes  it  for  granted  that  for  a  very  long  time,, 
or  always,  they  will  remain  in  that  state  of  definite  lack  of  strength. 

We  have  now  glanced  over  the  general  fatiguability  of  neurasthenics 
and  the  mechanism  of  their  exhaustion.  We  must  next  speak  of 
phenomena  of  the  same  order  but  whose  lack  of  logic  is  much  more 
apparent.     We  allude  to  the  localized  amyasthenias. 

We  have  spoken  here  of  certain  patients  who  are  exhausted  by  aU 
kinds  of  efforts  but  who  are  nevertheless  able  to  do  some  one  thing  with- 
out fatigue.  Here  we  have  to  do  with  individuals  whose  incapacity 
for  work  only  extends  to  a  given  group  of  muscles,  which  contract  under 
definite  conditions. 

We  meet  with  the  most  varied  types  of  such  fatigue  fixations.  The 
inability  to  remain  standing  for  any  length  of  time  is  a  symptom  of 


122  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

this  kind,  and  by  no  means  the  least  frequent.  It  is  needless  to  say 
that  this  difficulty  in  standing  is  found  in  association  with  other  symp- 
toms of  general  fatiguability.  But  one  may  also  find  it  alone.  These 
are  the  patients  who  can  walk  for  a  long  time,  can  lift  weights,  and 
swing  dumb-bells,  etc.,  and  yet  who  insist  that  they  are  exhausted  at  the 
end  of  a  few  minutes  or  even  after  a  few  seconds  of  standing  on  their 
feet.  There  are  some  who,  in  order  not  to  use  up  their  strength,  get 
to  the  point  where  they  are  obliged  to  make  their  toilet  in  instalments. 

The  mechanism  of  this  phenomenon  is  varied.  Very  often  it  is 
connected  with  a  lumbar  topalgia.  In  other  cases  it  is  the  memory  of 
some  previous  exhaustion,  caused  by  having  been  obliged  to  stand  for  a 
long  time,  which  causes  it.  We  know  that  standing  is  the  usual  attitude 
of  conversation.  Now,  while  he  is  conversing,  the  neurasthenic  throws 
himself  entirely  into  his  conversation,  and  it  is  not  rare  to  find  it 
resolving  itself  into  a  monologue  rather  than  a  dialogue.  What  fatigues 
him  then  is  not  so  much  the  standing  as  the  conversation,  during  which 
he  sometimes  expends  much  strength  without  paying  any  attention  to 
managing  or  saving  his  breath.  After  a  little  time  of  such  exercise, 
he  is  out  of  breath,  distressed,  and  exhausted.  There  is  an  error  in 
interpretation  which  makes  him  attribute  the  symptoms  of  a  wholly 
different  origin  to  the  fact  of  standing. 

These  are  the  initial  phenomena,  but  whether  it  is  a  topalgia  or  a 
previous  memory  which  is  present  at  the  beginning  of  the  symptoms  the 
results  are  the  same. 

It  must,  in  fact,  be  remembered  that  the  act  of  standing  is  not  an 
indifferent  phenomenon.  It  is  apt  to  cause  a  feeling  of  muscular  fatigue 
in  the  strongest  people,  and  one  cannot  remain  standing  for  any  very 
great  length  of  time  without  a  change  of  position,  by  letting  the  weight 
rest  first  on  the  right  leg  and  then  on  the  left  for  example,  in  order  to 
allow  the  muscular  groups  which  are  in  a  state  of  tonic  contraction 
time  to  rest.  But  even  under  these  conditions  one  finds  oneself  obliged, 
at  the  end  of  a  certain  length  of  time,  to  sit  down. 

How  would  this  affect  the  neuropath  who  is  troubled  by  a  lumbago 
or  who  recalls  the  exhaustion  he  felt  as  the  result  of  standing  upright 
at  some  former  time?  In  two  very  different  ways.  Sometimes  he  does 
not  hold  himself  erect.  He  is  continually  changing  his  position,  and  there- 
fore performs  what  is  a  much  more  rapidly  fatiguing  work,  according  as 
the  sensation  of  fatigue  is  reinforced  by  former  mental  representations 
of  the  same  kind.  Sometimes,  on  the  other  hand,  he  stiffens  himself, 
holds  himself  perfectly  still,  and  holds  his  breath,  and  the  time  during 
which  he  remains  standing  will  be  marked  to  some  degree  by  the  limit  of 
the  possible  duration  of  continued  voluntary  contraction.  This  dura- 
tion naturally  varies  according  to  the  energy  of  the  subject,  following 
the  intervention  or  not  of  respiratory  troubles  analogous  to  those  which 
we  have  already  described,  and  according  also  to  the  psychic  reinforce- 
ment of  the  mental  impression  which  is  felt.    In  both  ways  this  duration 


SYIVIPTOMS  IN  NEURO-MUSCULAK  APPARATUS.        123 

will  not  be  very  long,  and  it  is  chiefly  under  these  conditions  that  such 
patients,  standing  as  stiff  as  pickets,  are  apt  to  declare  themselves  ex- 
hausted at  the  end  of  a  very  short  time,  sometimes  not  more  than  a  few 
seconds. 

Here  it  is  a  question  of  an  amyasthenia  attacking  the  muscles  whose 
tonic  contraction  is  necessary  to  the  erect  position.  Other  muscular 
groups  may  be  attacked  in  a  still  more  specialized  way.  We  refer  to 
false  professional  cramps.    Here  is  a  most  characteristic  example. 

Miss  N.,  thirty-two  years  of  age,  is  a  talented  pianist,  in  love  with 
her  profession.  When  we  saw  her  in  1908,  she  had  been  obliged  to  give 
up  her  professional  work  almost  completely  for  nearly  eighteen  months. 
Each  time  that  she  tried  to  play  the  piano  she  would  invariably  be 
taken  by  feelings  of  very  painful  lassitude,  located  principally  in  the 
right  arm,  but  in  the  left  arm  also,  though  in  a  less  marked  degree.  In 
spite  of  all  her  efforts,  she  would  very  soon  be  overcome  by  the  pain 
and  obliged  to  stop. 

Ha\'ing  been  obliged  to  give  up  many  things  in  her  life,  and  seeing 
the  possibility  of  being  forced  to  abandon  her  art,  which  constituted 
her  only  moral  resource,  it  is  needless  to  say  that  she  was  very  profoundly 
depressed. 

The  origin  of  these  symptoms  went  back  to  a  slight  rheumatic  pain 
of  the  right  shoulder,  which  had  for  several  days  occasioned  rather 
painful  sensations,  and  on  account  of  which  she  was  obliged  to  give  up 
her  daily  musical  exercises.  Then  progressively,  at  the  same  time  that 
the  articular  pain  grew  dull,  before  disappearing  entirely,  the  phenomena 
which  we  have  just  described  appeared.  The  patient  had  consulted 
many  physicians,  and  the  most  remarkable  diagnoses  had  been  made, — 
myositis,  neuritis,  etc.  There  were  some  who  spoke  of  pianist's  cramp, 
and  who  hinted  to  our  patient  that  she  would  probably  be  obliged  to 
give  up  her  career.  The  greatest  variety  of  treatments  were  tried, — 
hydrotherapy,  mechanotherapy,  electrotherapy,  hypnotism,  local  applica- 
tions of  every  kind,  etc.  In  short,  the  patient,  being  more  and  more 
persuaded  that  her  trouble  was  chronic,  suffered  more  and  more  and 
grew  more  and  more  hopeless.  The  objective  examination  showed  noth- 
ing: the  articulations  of  the  shoulder,  the  elbow,  the  wrists,  and  the 
fingers  were  free.  The  muscles  were  supple,  there  was  no  painful  point 
anywhere  along  the  line  of  the  nerves,  and  sensibility  was  intact.  This 
patient  was  cured  in  a  few  weeks:  she  was  able  to  take  up  her  former 
occupations  in  their  entirety  when  the  mechanism  of  her  condition,  both 
in  its  present  and  past  history,  had  been  made  clear  to  us  and  to  her. 

It  was,  in  fact,  very  simple.  The  patient,  being  attacked  at  first  by 
real  rheumatic  symptoms,  was  overcome  with  dismay  at  the  possibility 
of  being  obliged  to  give  up  her  career.  She  insisted  on  working  in  spite 
of  her  pain.  She  insisted  upon  playing  in  spite  of  everything.  The 
result  was  that  she  at  once  stiffened  herself  to  the  task  in  order  to  play. 
She  thus  lost  all  her  suppleness,  and  the  fatigue  against  which  she  was 


124  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

struggling  by  steeling  herself  to  still  further  effort  only  appeared  more 
quickly,  more  insistently,  and  more  painfully. 

The  method  by  which  the  facts  of  this  phenomenon  were  brought  out 
deserves  to  be  described.  All  movements,  particularly  those  of  writing, 
were  accomplished  with  the  greatest  ease.  There  was  something  in 
that  which  convinced  us  of  the  functional  nature  of  the  phenomena 
experienced.  But  is  not  the  same  thing  true  of  professional  cramp  ? 
What  made  the  proof  clear  was  the  fact  that  writing  also  became 
fatiguing  to  our  patient,  and  gave  her  the  same  painful  impression  as 
in  playing  the  piano,  when  the  things  which  she  wrote,  instead  of  being 
a  simple  copy,  had  to  do  with  very  interesting  facts.  She  would  then 
hold  herself  tense;  her  pen  would  scratch  the  paper;  her  handwriting 
would  change  and  become  cramped.  In  a  case  of  this,  kind,  could  the 
immediate  facts  be  explained  by  the  intervention  of  any  mental  repre- 
sentation or  by  a  direct  auto-suggestion?  No,  we  do  not  think  so.  We 
hold  that  it  is  chiefly  a  phenomenon  of  disharmony,  very  similar  to 
those  which  we  have  previously  described.  The  specialized,  localized 
lassitude  of  our  patient  was  a  real  fatigue  legitimately  felt.  It  was 
such  as  any  woman  might  experience  if,  instead  of  playing  in  a  manner 
which  was  to  some  degree  automatic,  she  should  play  while  holding  her- 
self stiff  and  tense.  In  fact,  these  patients  are  at  the  start  in  the 
condition  that  others  are  in  after  several  hours  of  practice.  These  are 
not  patients  who  do  not  want  to  do  anything,  and  who  are  of  the  tired 
abulic  type  and  inhibited  by  a  wrong  mental  representation.  They  are 
patients  who,  because  they  are  only  too  anxious  to  do  things,  inhibit 
what  in  their  particular  cases  might  be  called  their  mechanism.  Although 
they  are  old  professionals,  they  behave  like  débutantes. 

We  have  also  seen  another  patient  whose  symptomatology  in  some 
points  was  almost  identical.  We  have  also  in  like  manner  seen  employees 
helpless  with  writer's  cramp,  which  was  due  to  phenomena  of  the  very 
same  nature  as  those  that  we  have  just  described. 

This  only  serves  to  show  how  necessary  it  is,  in  cases  like  these,  for 
the  diagnostician  to  be  careful  and  minute  in  his  examination,  for  a 
careless  diagnosis  may  lead  to  veritable  disaster,  careers  ruined,  and 
lives  spoiled.  One  appreciates  also  how  baneful  an  influence  a  physician 
may  exert  by  making  the  conviction  sink  deeper  into  the  patient's  mind 
that  he  may  have  some  definite  loss  of  power.  It  is  this  conviction  which, 
as  a  matter  of  fact,  is  at  the  base  of  the  whole  procession  of  symptoms. 
And  if  in  the  intermediary  mechanisms  we  find  disharmonious  facts 
coming  in,  which  have  hitherto  been  considered  of  little  value  in  what 
concerns  the  initial  principle  of  things,  we  agree  with  Dubois.  The 
important  psychological  fact,  however,  from  the  point  of  view  of  the 
moral  treatment  of  these  patients,  consists  in  this  :  in  their  case  the  will 
is  not  absent — quite  the  contrary — but  it  is  badly  applied. 

Phenomena  of  the  same  order  seem  to  us  to  be  able  to  account  for 
certain  clumsy  movements  of  which  the  patients  complain.     Some  will 


SYMPTOMS  IN  NEURO-MUSCULAR  APPARATUS.    125 

say,  for  example,  that  "they  can  hold  nothing  in  their  hands."  In 
many  cases,  it  is  true,  this  is  due  to  '  '  nervous  movements  ;  '  '  but  in  some 
circumstances,  nevertheless,  it  has  seemed  to  us  that  our  patients,  being 
cognizant  of  their  awkwardness,  or  believing  themselves  clumsy  in  some 
incident  that  has  accidentally  happened,  only  loosen  their  hold  upon 
objects  because  they  were  holding  them  too  tightly.  At  the  end  of  a 
short  time  their  quasi-spasmodic  contraction  is  relaxed  and  the  object 
falls.  It  is  true  of  nervous  people  more  than  of  others  that  trying  to  do 
one's  best  is  fatal  to  doing  well, 

2.  Disturbances  of  Equilibrium.— In  order  thoroughly  to  understand 
the  mechanism  of  disturbances  of  equilibrium  which  one  observes  in  the 
course  of  the  psychoneuroses,  we  are  obliged  to  refer  to  clinical  observa- 
tion. We  might  add  that  it  seems  useless  to  call  attention  to  the  fact 
that  the  observations  to  which  we  refer  are  of' recent  date.  We  are  not 
wholly  convinced,  in  fact,  but  that  «many  troubles  which  might  have 
been  described  at  one  time,  when  hysteria  was  a  more  or  less  consciously 
cultivated  disease,  were  nothing  more  than  troubles  due  to  education, 
for  which  simulation  and  suggestion  were  both  partly  responsible. 

We  shall,  therefore,  first  turn  back  to  some  observations  in  which 
all  the  cases  which  we  have  been  able  to  study  are  almost  identical  one 
with  the  other. 

Here  is  the  first  history,  already  published  by  one  of  us,  which 
furnishes  an  example  of  an  hysterical  symptom  following  immediately 
and  bearing  a  direct  relation  to  an  emotional  shock.  It  was  the  case  of 
a  young  girl  who,  on  seeing  her  dog,  to  which  she  was  very  much 
attached,  run  over  by  a  train  on  a  railway  crossing,  felt  her  limbs  give 
way  beneath  her,  so  that  she  sank  down  on  the  ground.  She  had  to  be 
carried  home.  Thenceforth  she  could  no  longer  walk  or  stand  up.  If 
she  tried  to  get  up,  she  would  immediately  fall.  Nevertheless,  when  she 
w^as  examined  in  bed,  there  was  no  disturbance  of  general  sensibility  nor 
of  the  muscular  sense,  nor  any  motor  incoordination.  Her  muscular 
force  was  intact,  she  could  draw  up  and  stretch  out  her  thighs,  legs,  and 
feet;  she  could  resist  passive  movements  when  pressure  was  brought  to 
bear  on  any  part.  It  was  not  a  case  of  paralysis,  but  of  disturbance  of 
equilibrium.  This  patient  was  cured  in  eight  days  by  isolation  with 
psychotherapy. 

For  the  last  twenty-seven  years  a  lady,  fifty-two  years  of  age,  had 
been  confined  to  her  room  and  could  not  walk  without  hanging  on  some- 
body's arm.  Hers  was  a  case  of  great  emotional  fear,  whose  symptoms 
had  a  very  curious  and  definite  origin. 

When  she  was  twenty-six  years  old  and  had  been  married  two  years, 
she  was  dining  one  day  in  town  with  her  husband.  In  going  down  the 
stairway  of  her  hostess's  house,  either  because  she  was  affected  by  the 
cold  or  perhaps  because  the  dishes  which  had  been  served  at  dinner  had 
disagreed  with  her,  she  was  taken  with  vertigo  and  giddiness,  and  finally 


126  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

with  vomiting.  She  was  taken  home  in  a  carriage.  The  next  day  she 
found  that  she  was  not  able  to  get  up.  The  moment  that  she  stood  upon 
her  feet,  it  seemed  to  her  that  everything  was  turning  around  her  and 
that  she  was  going  to  fall.  A  physician  was  called  in,  but,  instead  of 
attributing  her  trouble  to  the  results  of  indigestion,  he  made  the  diag- 
nosis of  haemorrhage  of  the  brain.  He  told  her  husband  that  it  would 
be  impossible  for  his  wife  to  live  in  Paris  ;  that  it  would  inevitably  follow, 
when  she  went  out  again,  that  her  equilibrium  would  never  be  perfect, 
and  she  would  be  exposed  to  the  danger  of  accidents  in  the  traffic  of  a 
great  city.  The  husband  was  convinced.  lie  made  a  home  for  his  wife 
in  the  suburbs  of  Paris,  but,  as  his  business  took  him  to  the  city,  he 
was  obliged  to  leave  every  morning  and  not  return  till  evening.  His 
wife,  left  alone  all  day,  did  not  dare  go  out  of  her  room,  where  she 
lived  like  a  prisoner.  Things  went  on  in  this  way  indefinitely.  Every 
attempt  that  she  made  to  get  up  or  to  walk  or  go  out  being  followed 
immediately  by  the  same  symptoms  of  loss  of  equilibrium,  she  finally, 
after  a  certain  time,  gave  up  trying  to  make  any  eifort,  and  thereafter 
she  never  walked  unless  there  was  some  one  to  hold  her  up. 

On  examination,  it  was  found  that  in  bed  this  lady  had  preserved 
the  muscular  strength  of  her  lower  limbs,  but  the  moment  that  she 
wanted  to  get  up  she  would  sink  down,  either  all  at  once  or  very  quickly. 
She  could  sometimes  take  a  few  uncertain  wavering  steps  before  she 
wholly  lost  her  equilibrium. 

At  the  end  of  a  month's  treatment  these  symptoms,  which  were 
purely  functional  in  their  nature  and  which  for  twenty-seven  years 
had  spoiled  the  best  part  of  her  life,  had  completely  disappeared. 

A  third  example  is  furnished  us  by  a  lady  of  thirty-two,  who  was 
very  emotional.  She  had  been  sick  three  years  when  we  saw  her  for 
the  first  time.  The  physicians  who  had  treated  her  made  a  diagnosis 
of  a  disease  of  the  spinal  cord.  They  had  made  several  applications 
of  hot  irons  and  had  put  blisters  upon  her.  They  had  given  her  mer- 
curial injections  and  large  doses  of  iodides,  etc.  In  short,  she,  as  well 
as  everybody  around  her,  was  convinced  of  the  organic  nature  of  her 
disease,  and  that  it  was  probably  incurable.  She  came  to  us  hobbling 
painfully  on  two  canes,  only  putting  one  leg  forward  when  she  had  so 
placed  one  of  her  canes  that  she  was  sure  that  she  could  lean  firmly  and 
securely  upon  it.  When  her  supports  were  taken  away  from  her  and 
we  tried  to  make  her  walk,  she  held  out  her  arms  as  if  to  balance  herself, 
then  put  one  foot  forward.  It  would  then  often  happen  that  her  limbs 
would  suddenly  give  way,  and  she  would  try  to  recover  herself  by  draw- 
ing herself  up  quickly.  In  the  course  of  these  two  movements, — the  one 
involuntary  and  passive,  and  the  other  sudden  and  voluntary,  but  in- 
coordinated, — she  would  always  lose  her  balance,  and  her  faith  in  the 
gravity  of  her  disease  would  only  be  the  stronger. 

Objectively  the  patient  showed  no  sign  of  organic  affection.  But 
we  discovered  very  easily  the  existence  of  a  left  hysterical  hemiplegia. 


SYMPTOMS  IN  NEURO-MUSCULAR  APPARATUS.         127 

which  was  very  slight,  and  which  had  passed  wholly  unnoticed  by  the 
patient  herself  and  by  the  physician. 

The  origin  or  cause  of  the  affection  was  more  difficult  to  discover, 
and  it  was  only  after  some  time  that  we  succeeded  in  obtaining;  a 
complete  confession  from  our  patient.  She  was  living  with  her  husband 
and  mother-in-law.  The  latter  made  her  life  anything  but  happy.  She 
was  the  regular  mother-in-law  of  the  melodrama  and  continually 
aggravated  her  daughter-in-law,  who,  always  trembling  lest  her  house- 
hold peace  should  be  upset,  got  to  the  point  where  she  could  not  even 
see  her  mother-in-law  without  having  a  serious  emotional  disturbance. 
*'Each  time  that  I  saw  her,"  she  told  us,  "I  felt  as  though  I  were  ready 
to  fall.  My  limbs  gave  way  under  me."  These  impressions,  which  at 
first  were  produced  only  when  in  the  presence  of  the  one  who  caused 
them,  ended  by  being  felt  continuously  as  the  young  woman  lived  in  the 
constant  recollection  of  a  scene  that  had  just  passed  or  in  the  anticipa- 
tion of  one  to  come. 

A  few  weeks  of  calm  with  appropriate  treatment  were  sufficient  to 
cause  these  symptoms  to  disappear. 

In  the  three  observations  which  we  have  just  given  we  have  to  deal 
with  objective  disturbances  of  equilibrium.  In  a  very  great  number  of 
cases  the  patients  complained  of  purely  subjective  troubles.  We  shall 
come  across  these  patients  again  when  we  study  vertigo  and  sensations 
of  dizziness.  For  the  time  being,  these  are  the  only  objective  disturbances 
without  vertigo  that  we  shall  interpret. 

Stasohasophohiaj  which  is  confused  with  what  is  called  paralytic 
astasia-abasia,  is  a  very  peculiar  phenomenon,  but  one  whose  purely 
mental  mechanism  is  easy  to  grasp. 

In  a  normal  state,  when  we  are  standing  still  or  when  we  walk,  our 
static  or  kinetic  equilibrium  is  assured  by  a  series  of  tonic  muscular 
contractions  which,  though  they  have  an  organic  centre  of  reinforcement 
in  the  cerebellum  correspond  none  the  less  to  special  mental  representa- 
tions, and  which  act  so  that  in  a  given  situation  the  tonic  contractions 
are  instinctively  and  automatically  increased  or  diminished. 

A  comparison  with  the  phenomena  of  speech  will  perhaps  better 
explain  our  idea.  Wl\en  a  child  learns  to  speak  he  registers  what  have 
been  called  motor  images  of  articulation.  When  he  learns  to  hold 
himself  upright,  or  to  walk,  he  registers  motor  images  of  static  or 
kinetic  equilibrium.  When  he  knows  how  to  talk,  the  functioning  of 
the  motor  images  of  articulation  become  automatic  and  unconscious. 
When  he  knows  how  to  walk  and  to  stand  up  straight,  the  corresponding 
motor  representations  have  also  become  absolutely  instinctive. 

But  let  there  be  a  lesion  which  destroys  the  base  of  the  third  left 
frontal  convolution,  and  the  idea,  though  persisting,  cannot  be  expressed 
by  a  spoken  word.  How  natural  that  the  subject  should  be  greatly  upset 
on  not  finding  the  words  he  wants  and  that  he  should  hesitate  and 
stutter. 


128  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

The  same  thing  is  true  for  walking  and  standing;  and,  if  one  can 
conceive  the  existence  of  disturbances  of  equilibrium  from  cerebellar 
lesions,  with  localized  or  generalized  affections  of  the  muscular  tonus, 
one  can  also  conceive  of  the  existence  of  disturbances  of  the  equilibrium 
dependent  upon  the  loss  of  the  mental  representations  corresponding  to 
the  necessary  contractions  to  insure  equilibrium.  The  patient  no  longer 
knows  how  to  stand  upright  or  to  walk.  He  has  forgotten  how  he  ought 
to  begin,  just  as  we  have  seen  how,  under  the  influence  of  a  lesion  or  an 
emotion,  our  subject  either  could  not  or  did  not  know  how  to  find  the 
words  he  wanted. 

As  to  the  various  influences  capable  of  inducing  these  peculiar  mani- 
festations, they  are  of  two  kinds,  which,  moreover,  are  apt  to  be  con- 
fused. Sometimes  it  is  a  question  of  emotional  shock,  and  sometimes 
phenomena  of  a  phobic  nature  are  the  cause. 

Let  us  suppose  that  it  is  the  question  of  an  emotion.  Here  again  we 
find  the  rôle  of  specialized  emotion  which  we  have  already  had  to  point 
out  so  many  times.  The  giving  way  of  the  limbs  is  an  emotional  form 
of  reaction  that  is  well  known  and  classic.  It  seems  that  among  certain 
subjects  when  the  emotional  current  is  once  directed  it  will  always  follow 
the  same  channel,  and  that,  whatever  may  be  the  nature  or  the  intensity 
of  the  emotion  experienced,  it  will  always  be  translated  in  the  same  way. 
A  young  woman,  afflicted  with  hysterical  paraplegia,  remembered  that 
it  was  always  usual  for  any  emotion  to  'Hake  her  in  her  limbs."  All 
that  was  necessary  in  her  case  was  a  more  intense  emotion  than  usual 
for  the  purely  classic  symptoms  to  become  continuous.  One  can  con- 
ceive, therefore,  from  this  that  by  an  analogous  mechanism  stasobaso- 
phobias  may  be  produced  by  emotional  shock,  or  rather  by  the  crystalliza- 
tion in  some  way  of  a  specialized  emotional  action. 

Under  other  circumstances  it  is  a  question  of  phobic  phenomena. 
Here  things  may  be  interpreted  in  a  double  sense.  Sometimes  the 
patients  are  so  convinced  of  their  helplessness  that  they  do  not  even 
make  enough  effort  to  enable  them  to  stand  up  on  their  feet  or  to  take  a 
single  step.  They  just  let  themselves  go,  and  sink  down  helpless.  Our 
second  patient  would  be  a  good  example  of  this  mechanism.  Elsewhere 
the  phobic  action  is  exercised  by  the  intermediation  of  the  emotional 
action.  The  patients  are  so  afraid  of  falling  that  they  are  always  in  a 
more  or  less  intense  state  of  excitement,  which  is  accompanied  by  a 
more  or  less  perpetual  forgetfulness  of  the  coordinate  efforts  which  they 
must  make  in  order  to  stand  on  their  feet  or  walk.  The  rather  fre- 
quent association  of  agoraphobia  with  stasobasophobia  brings  this 
mechanism  into  evidence.  These  patients,  who,  being  agoraphobics,  are 
seized  with  a  feeling  of  dread  the  moment  that  they  see  an  open  space 
before  them,  are  under  these  conditions  often  subject  to  feeling  their 
limbs  give  way  beneath  them,  and  display  every  evidence  of  the 
emotional  pathogeny  which  we  have  just  been  trying  to  explain. 

In  fact,  basostasophobia  is  a  pure  phobic  manifestation  or  one  asso- 


SYMPTOMS  IN  NEURO-MUSCULAR  APPARATUS.        129 

ciated  with  an  emotion  or  else  an  exclusively  emotional  manifestation. 
Let  us  add  that  the  symptomatic  ensemhle  is  not  always  complete, — 
that  there  are  patients  who  are  only  basophobic  and  who  still  find  it 
possible  to  stand  with  varying  degrees  of  ease. 

We  now  come  to  astasia-abasia.  The  phenomenon  which  constitutes 
it  has  been  defined  by  Charcot  and  Richer  as  motor  helplessness  of  the 
lower  limbs,  through  lack  of  relative  coordination  in  walking  (abasia) 
and  in  standing  upright  (astasia).  It  is  a  functional  ataxic  symptom 
involving  walking  and  standing.  The  patients  whom  we  have  just  now 
been  studying  had  lost  all  ideas  of  mental  representations  correspond- 
ing to  the  tonic  contractions  necessary  to  maintain  equilibrium,  but 
here  it  is  quite  another  matter.  There  is  no  suppression,  but  there  is 
anomaly  due  to  incoordination.  The  muscular  contractions  may  be 
present,  but  they  are  not  adaptive,  and  only  produce  an  unstable 
equilibrium. 

On  the  other  hand,  we  are  not  wholly  convinced  from  the  facts  but 
that  there  is  a  possibility  of  considering  astasia-abasia  on'ly  as  a 
syndrome  wide  enough  to  take  in  the  most  diverse  cases  which  unite  the 
objective  disturbances  of  walking  and  standing. 

In  the  first  place,  there  is  no  true  clinical  type  of  astasia-abasia. 
There  are  as  many  different  aspects  as  there  are  patients.  Then  that 
form  of  astasia-abasia  of  the  so-called  paralytic  type,  that  in  which  the 
patient  cannot  leave  his  bed,  seems  to  us  likely  to  be  confused  with  staso- 
basophobia.  To  consider  this  form  as  a  maximum  of  incoordination  does 
not  seem  to  us  to  conform  to  clinical  reality. 

As  for  the  other  clinical  types  of  astasia-abasia,  they  also,  we  feel, 
should  be  considered  with  some  reservation. 

We  have  seen  hysterical  choreas  whose  walking  was  disturbed  by  the 
incoordinated  movements.  We  have  seen  people  afflicted  with  a  general 
tic  taken  with  a  falling  attack  during  which  their  limbs  would  give 
way  sideways  or  vertically.  We  have  seen  the  association  of  stasobaso- 
phobia  with  hysterical  hemiplegia  giving  rise  to  supplementary  dis- 
turbances. Our  third  observation  was  of  a  typical  case,  and  we  have 
seen  other  similar  cases.  One  of  us  had  the  opportunity  of  seeing  at  a 
former  time  a  certain  number  of  patients  afflicted  with  so-called  chorei- 
form or  shaking  or  leaping  astasia-abasia.  Since  the  cultivation  of 
hysteria  has  been  given  up  he  has  not  met  with  a  single  example,  and 
he  is  inclined  to  think  that  what  he  saw  were  symptoms  which  were 
more  or  less  directly  suggested. 

In  fact  paralytic  astasia-abasia  is  confused  with  stasobasophobia  with- 
out any  possible  differentiation.  It  seems  to  us  that  what  has  been 
designated  under  the  name  astasia-abasia  apart  from  stasobasophobia, 
which  has  already  been  analyzed,  consists,  on  the  one  hand,  of  the 
symptoms  which  hysterics  have  learned  to  show,  and  on  the  other,  of 
essentially  morbid  associations  to  which,  in  a  more  or  less  marked  phobic 
9 


130  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

condition,  are  superadded  the  phenomena  resulting  from  choreas,  tics, 
paralytic  and  paretic  conditions. 

Does  that  mean  that  incoordinated  motor  states  of  a  neuropathic 
origin  cannot  exist?  A  wider  view  must  be  taken,  and,  if  one  confines 
oneself  to  looking  upon  incoordination  as  a  non-adaptation  of  move- 
ments intended  for  a  definite  end,  it  is  very  certain  that  phenomena 
of  this  order  are  met  with  and  very  frequently  among  neuropaths.  But 
this  is  not  a  question  of  ataxia  properly  so  called.  It  is  neither  a 
central  ataxia  nor  a  peripheral  ataxia.  The  movements  made  are 
coordinated.  The  error  lies  in  the  judgment  which  the  subject  brings 
to  bear  upon  his  movements  in  order  to  accomplish  them.  The  move- 
ments which  follow  are  perhaps  not  adapted  to  the  end  in  view,  but 
they  are  adapted  to  the  ideomotor  representation.  These  phenomena 
enter,  in  fact,  into  the  class  of  disharmonies  of  psychic  origin  of  which 
we  have  already  spoken.  A  healthy  subject  is  on  the  point  of  losing 
his  equilibrium,  in  a  certain  sense,  as  a  consequence  of  a  false  step. 
In  order  to  save  himself,  he  will  go  through  a  series  of  movements 
which  will  throw  him  to  the  other  side.  Can  one  then  say  that  he  lacks 
coordination  ?  The  adaptation  has  been  insufficient  on  account  of  an 
error  of  judgment.  But,  having  once  made  this  error,  the  rest  of  his 
movements  have  been  coordinated  and  the  end  accomplished. 

It  is  the  same  thing  with  neuropaths,  with  this  difference,  that,  in 
certain  subjects,  it  does  not  require  any  abnormal  phenomenon  or  any- 
thing outside  of  themselves  to  produce  it.  All  that  is  necessary  and 
sufficient  is  for  them  to  have  an  error  in  the  mental  representation,  which 
is  sometimes  primitive,  and  disharmonie  movements  will  be  produced, 
creating  a  real  incoordination,  which,  physiologically  and  pathologically 
speaking,  is  nevertheless  not  a  true  ataxia. 

Here,  for  example,  are  basophobics  who  try  to  walk  because  they 
have  been  convinced  of  the  necessity  of  re-educating  themselves.  At 
first  they  do  not  dare  to  put  one  foot  before  the  other.  Then  they 
plunge  forward  and  all  at  once  take  such  a  stride  that  they  lose  their 
balance.  '  It  is  practically  the  same  thing  as  stepping  off  into  the  air, 
which  will  throw  the  best-balanced  person  to  the  ground.  More  timid 
than  ever,  they  will  at  first  try  to  widen  the  base  of  support  and  will 
straddle  their  legs  in  such  a  way  that  they  will  resemble  the  lines  of  an 
arrow-head.  Then  they  try  to  make  a  forward  movement.  It  goes 
without  saying  that  the  very  position  which  they  have  taken  disturbs 
their  centre  of  gravity  so  that  they  cannot  perform  this  movement  with- 
out losing  their  balance.  Other  patients  begin  by  stiffening  all  their 
muscles,  which  they  relax  on  one  side  in  order  to  advance.  It  is  plain 
that  they  will  be  overcome  by  the  contraction  of  the  opposite  side. 

One  could  without  difficulty  go  on  enumerating  such  disharmonie 
phenomena.  May  it  not  be  possible  that  troubles  of  this  kind  which 
have  been  considered  as  astasic-abasic  are  developed  more  often  in  the 
basostasophobics  ?    But  may  they  not  also  exist  in  individuals  who,  for 


SYMPTOMS  IN  NEURO-MUSCULAR  APPARATUS.    131 

one  reason  or  another,  are  not  sure  of  their  static  or  kinetic  equilibrium  ? 
One  can  see,  according  to  this  conception  which  we  hold  concerning  them, 
that  they  have  nothing  to  do  with  the  real  disturbances  of  motor 
coordination. 

On  the  other  hand,  phenomena  of  the  same  order  exist  elsewhere  than 
in  the  lower  limbs.  We  have  already  pointed  out  that  the  localized 
amyasthenias  and  awkwardness  of  neuropaths  were  often  due  to  mani- 
festations of  this  kind.  We  do  not  insist  upon  it,  and  shall  content 
ourselves  with  drawing  attention  to  the  fact  that  the  common  char- 
acteristic of  this  kind  of  motor  disturbance  is  overshooting  the  mark. 
We  are  far  from  believing,  as  may  be  seen,  the  conception  that  the 
majority  of  neuropathic  manifestations,  and  particularly  those  in  neuras- 
thenics, are  disturbances  due  to  lack  of  will  power.  Other  disturbances 
of  equilibrium,  of  almost  exactly  the  same  mechanism,  have  to  do  with 
the  vertigoes  which  are  so  frequent  in  neuropaths.  We  shall  take  them 
up  when  we  study  vertigo  itself.  The  latter,  inasmuch  as  it  constitutes 
a  disturbance  of  equilibrium,,  should  be  studied  with  the  mental  mani- 
festations properly  so  called,  for  reasons  which  we  shall  develop  later. 

3.  Choreas,  Choreiform  Movements,  and  Tremors. — ^We  would  like  to 
glance,  in  this  paragraph,  at  the  general  group  of  involuntary  movements 
which  may  be  observed  in  the  course  of  the  psychoneuroses.  We  shall 
not  study  the  more  or  less  hereditary  tics  or  tremors  of  degenerates. 
These  latter  are  symptoms  associated  with  special  mental  conditions,  and 
which  on  this  account  do  not  come  within  the  scope  of  our  work. 

Three  types  of  involuntary  movements  may  be  observed  in  neuro- 
paths. There  are  choreas,  which  are  the  exclusive  property  of  hysteria 
so  far  as  the  neuropathic  manifestation  is  concerned.  In  neurasthenics 
as  well  as  in  hysterics,  we  may  find  tremx)rs.  Finally,  there  are  in 
certain  subjects,  and  particularly  among  children  or  adolescents,  little 
involuntary  movements  which  in  some  measure  resemble  tics  if  one  con- 
siders them  alone  and  thinks  only  of  the  movement  produced.  These 
are  false  tics. 

Hysterical  chorea  is  a  well-known  phenomenon.  Like  all  the  choreas 
it  consists  in  the  appearance,  in  those  subjects  who  are  affected  by  it,  of 
involuntary  irregular  and  incoordinate  movements.  It  seems  to  us 
that  the  classical  descriptions  of  hysterical  chorea  include  two  very  dif- 
ferent kinds  of  facts.  It  seems  to  us  that  the  whole  class  of  choreas  with 
rhythmic  movements  which  are  no  longer  incoordinated,  but  recur  at 
irregular  intervals  to  reproduce  movements  made  in  ordinary  life,  such 
as  leaping,  dancing,  etc.,  should  be  eliminated  at  the  start  from  the  list 
of  the  symptoms  of  the  psychoneuroses  such  as  we  understand  them.  As 
a  matter  of  fact,  all  these  types  of  chorea  have  almost  wholly  disappeared 
from  view  in  recent  years.  It  seems  to  us  that  here,  as  is  the  case  with 
so  many  other  hysterical  manifestations,  they  were  the  direct  results  of 
cultivation  and  of  more  or  less  direct  suggestions,  which  required  essen- 
tially, but  to  a  varying  degree,  the  willing  cooperation  of  the  patient. 


132  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

Major  hysterical  chorea  is  not  very  frequently  seen.  Here  the  wild 
movements  go  to  their  furthest  limit.  This  major  chorea  may  be 
unilateral — ^hemichorea — and  be  accompanied  or  not  by  hemianaesthesia. 
One  of  us  has  seen  a  case  in  which  the  incoordinated  movements  were 
extremely  marked  in  both  upper  and  lower  limbs.  On  the  other  hand, 
the  minor  hysterical  choreas  appearing  more  frequently  in  children, 
and  particularly  in  girls  of  from  thirteen  to  seventeen,  after  puberty, 
are  very  frequent  manifestations.  There  is  not  a  clinic  at  the 
Salpêtrière  where  one  does  not  see  two  or  three  during  a  consultation. 
In  the  service  of  one  of  us  at  the  Salpêtrière  there  have  been  from  ten 
to  twenty  of  these  patients  a  year  under  treatment  by  isolation. 

More  often  these  are  merely  slight  symptoms,  little  convulsive  move- 
ments of  the  hand  with  awkwardness  in  taking  hold  of  things,  slight 
shakings  in  the  arms  or  in  the  shoulders,  and  slight  contractions  of  the 
muscles  of  the  face.  It  is  very  rare  to  find  any  serious  affections  of  the 
lower  limbs.  There  may  be  slight  trembling  at  different  times  during 
the  day,  which  incidentally  affects  the  gait,  but  that  is  about  all. 

Hysterical  chorea  may  exist  on  one  side  alone.  This  is  true  for 
perhaps  twenty-five  out  of  a  hundred  cases.  More  often  it  is  bilateral. 
Taking  it  all  in  all,  it  is  a  neuropathic  phenomenon  which  is  generally 
mild,  and  rapidly  recovers  under  appropriate  treatment. 

What  is  the  origin  of  these  troubles?  Very  often  they  appear  co- 
incident with  an  emotional  disturbance.  But  it  is  rather  rare  to  find 
them  established  with  their  full  intensity  at  the  start.  They  are 
progressive  troubles,  starting,  in  the  majority  of  cases,  either  in  the 
hand  or  in  the  shoulder,  and  radiating  from  that  point,  while  the  attacks 
increase  in  frequency  and  intensity.  We  do  not  believe  that  they  are 
due  to  a  purely  emotional  disturbance,  for  different  factors,  it  seems  to 
us,  enter  into  play.  Suggestion  by  imitation  explains  a  certain  number 
of  cases.  Sometimes  there  are  epidemics  in  a  school  where  chorea — 
by  suggestive  action — becomes  contagious.  Sometimes  the  patients  are 
children  living  with  neuropathic  parents  who  have  some  form  of  tic. 
We  have  seen  one  case  of  this  kind  in  a  child  who  was  taken  with 
progressive  chorea  following  an  attack  of  nerves  on  the  part  of  her 
mother.  She  had  seen  her  throwing  herself  around,  and  the  move- 
ments which  the  child  made  were  nothing  more  than  attempts  to  imitate 
the  mother. 

At  other  times,  and  the  case  is  very  frequent,  they  occur  in  children 
who  have  been  amusing  themselves  by  making  faces  or  some  more  or  less 
extravagaut  movements,  and  who  end  up  by  making  automatic  pseudo- 
tics.  One  of  us  has  seen  several  examples  of  this  kind,  among  others 
that  of  a  little  girl  nine  years  of  age,  who  for  two  years  had  been  sent 
away  from  every  school  because  she  would  incessantly  turn  her  head  so 
that  she  could  tuck  her  chin  under  her  right  arm.  She  was  cured  after 
eight  days  of  isolation. 

Under  other  circumstances  they  occur  in  children  who  hold  them- 


SYMPTOMS  IN  NEURO-MUSCULAR  APPARATUS.    133 

selves  badly  or  who  are  awkward.  They  are  told  to  stand  up  straight, 
and  are  reproached  because  they  '^can  hold  nothing  in  their  hands." 
Following  this,  choreic  movements  may  develop  as  a  sort  of  objective 
excuse.  Again,  chorea  may  be  a  sign  of  constitutional  psychomotor 
mental  instability,  but  it  then  occurs  in  psychopathic  children,  who  are 
not  included  in  our  present  study.  Here  the  movements  are  always 
much  more  apt  to  be  incoordinated  voluntary  movements  than  true 
choreic  movements. 

What,  then,  in  these  manifestations  is  the  part  played  by  emotion, 
which  clinically  is  active  in  establishing  them  as  well  as  bringing  about 
their  occasional  intercurrent  modifications? 

It  seems  to  us  that  emotion  must  act  by  favoring  the  initial  sug- 
gestion. On  the  other  hand,  all  involuntary  movements  and  all 
incoordinations,  even  of  organic  origin,  are  always  increased  by  emotion. 
It  would  seem  that  even  in  subjects  afflicted  by  these  troubles  there  exists 
a  certain  more  or  less  conscious  power  of  regulation  which  emotion  causes 
to  disappear,  while  at  the  same  time  increasing  the  intensity  of  the 
objective  phenomena. 

This  is  all  evidently  hypothetical  ;  but,  while  we  fully  admit  the  rôle 
of  emotion  in  the  genesis  of  hysterical  choreas,  we  nevertheless  think 
that  direct  or  indirect  suggestion  is  often  cause  for  them. 

Tremor  occurs  in  neurasthenic  patients  as  well  as  in  hysterics. 
Neurasthenics  are  sometimes  seized  in  their  upper  limbs  with  small, 
quick,  irregular  tremors.  Sometimes  one  can  see  in  these  patients  a  real 
intention  tremor,  which  is  exaggerated  in  proportion  to  the  will  brought 
to  bear  upon  the  voluntary  movement. 

This  tremor  frequently  appears  under  the  stress  of  emotion,  but 
after  this  has  passed  the  tremor  disappears  more  or  less  quickly,  to 
reappear  under  the  influence  of  the  same  causes  which  created  it.  Under 
all  circumstances  rest  causes  it  to  disappear. 

The  tremor  of  hysterics  is  essentially  polymorphous.  Appearing 
after  any  moral  or  physical  shock  it  may  have  any  rhythm.  As  a  matter 
of  fact,  one  finds  in  hysterics  a  vibratory  tremor  with  short,  rapid 
oscillations,  which  may  be  either  localized  or  general,  and  may  last  only 
for  a  few  hours  after  an  hysterical  attack  or  may  in  some  cases  become 
permanent.  It  persists  in  spite  of  rest  and  only  disappears  during  sleep. 
Movement  and  emotions  exaggerate  it. 

Slight  rhythmic  tremor  is  the  most  frequent.  There  are  several 
forms  of  it. 

Intention  tremor  of  the  Rendu  type  disappears,  at  least  for  a  few 
moments,  during  absolute  rest.  It  is  exaggerated  by  movement,  and  its 
oscillations  increase  in  extent  in  proportion  to  the  movement  which  is 
made.  When  the  patient  stands  up,  if  he  tries  to  walk,  or  even  if  he 
remains  seated  for  a  certain  time,  the  whole  body  is,  as  it  were,  shaken 
by  tremor. 

Localized  in  the  lower  limbs  this  form  of  tremor  constitutes  the 


134  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

paraplegic  type,  and  simulates  the  tremor  of  spasmodic  paraplegia; 
but  suddenly  straightening  the  foot  will  stop  the  trembling  instead  of 
increasing  it. 

Purely  intention  tremor  exists  only  during  movement  and  disappears 
wholly  during  rest. 

It  is  in  the  group  of  slight  rhythmic  tremors  that  hysterotoxic  tremors 
belong,  like  those  which  are  met  with  in  mercurial  poisoning  (Letulle) . 

The  slow  tremors  of  hysterics  have  rather  a  wide  swing.  They  may 
be  generalized  or  localized.  All  these  kinds  of  tremor  may  be  com- 
bined or  succeed  one  another  in  the  same  subject,  becoming  complicated 
by  choreiform  movements  and  incoordinations  of  all  kinds,  which  give 
them  an  essentially  polymorphous  aspect. 

At  the  present  moment  we  have  only  very  uncertain  data  concern- 
ing the  pathophysiological  physiognomy  of  tremor  in  general.  Our 
reluctance  to  express  ourselves  concerning  the  mechanism  of  their  appear- 
ance will,  therefore,  naturally  be  understood. 

It  is  perfectly  evident  that  emotion  is  able  directly  to  cause  tremor. 
In  popular  parlance  any  one  speaking  of  the  effect  of  emotion  will  say 
that  he  *' trembled  from  head  to  foot."  It  is  quite  possible  that  we 
still  have  to  deal  with  that  specialized  action  of  emotion  which  we 
have  already  spoken  of  so  many  times.  A  person  who  has  once  trembled 
under  the  influence  of  an  emotion  will  be  seized  with  trembling  the 
next  time  he  is  overcome  by  emotion. 

And  yet,  is  it  not  possible  to  conceive  that  the  tremor  may  be  en- 
couraged by  itself?  The  fear  of  trembling  and  the  discomfort  which  it 
causes  the  subject  who  experiences  it  become  factors  of  the  emotion 
which  make  the  trembling  lasting.  It  is  possible  in  this  way  to  explain 
that  tremor  of  neurasthenics  which  disappears  during  rest  and  cahn, 
but  reappears  with  every  emotion.  The  fact  that  the  tremor  may  be 
exaggerated  during  any  volitional  act  is  also  explained  in  this  way. 
For  the  nearer  a  person  approaches  to  the  desired  end  the  more  his 
emotional  condition  is  increased  by  the  fear  that  he  may  not  attain  it. 

There  seems  to  us  no  shadow  of  doubt  but  that  formerly  a  great 
number  of  cases  of  hysterical  tremors  were  largely  due  to  more  or  less 
voluntary  suggestion  and  imitation.  But  this  interpretation  nevertheless 
does  not  seem  to  be  applicable  to  all  the  clinical  facts. 

It  appears  to  us  that  to  a  certain  degree  tremor  may  be  considered 
as  a  phobic  manifestation.  If,  in  fact,  one  admits  that  the  theories  of 
Debove  and  Boudet  explain  the  pathogeny  of  this  trouble,  which  theories 
apply  chiefly  to  intention  tremor,  and  make  the  phenomenon  depend 
upon  contraction  of  antagonistic  muscles,  one  can  conceive  that  any 
more  or  less  subconscious  movement  of  arrest  may  create  a  tremor  during 
any  voluntary  movement,  for  the  essential  characteristic  of  phobic  mani- 
festations consists  in  phenomena  of  arrest  or  recoil. 

On  the  other  hand,  all  that  it  is  necessary  for  a  healthy  person  to 
do  to  make  a  limb  tremble  is  to  stiffen  it.     One  sees,  therefore,  that 


SYMPTOMS  IN  NEURO-MUSCULAR  APPARATUS.    135 

certain  tremors  may  persist  by  reason  of  the  very  state  of  contraction 
into  which  the  subject  puts  himself  when  he  becomes  concerned  about 
his  tremors  and  tries  to  stop  them. 

Finally,  there  exist  a  whole  series  of  nervous  movements,  which, 
however,  are  only  secondarily  neuropathic,  to  which  we  might  give  the 
name  '  '  perfection  movements.  '  '  An  illustration  will  explain  better  what 
we  mean  by  this  term. 

"We  were  called  to  treat  a  young  man,  sixteen  years  of  age,  for 
''nervous  movements."  These  were  located  in  the  left  shoulder  and 
the  right  side  of  his  face.  Sometimes  our  patient' w^ould  be  seized  two 
or  three  times  during  the  day,  and  sometimes  twenty  times  in  an  hour, 
with  a  sudden  contraction  of  the  left  shoulder,  which  he  would  raise. 
He  would  also  experience  contractions  of  the  side  of  his  face  in  the 
same  irregular  way,  but  as  a  whole  less  frequently  than  in  the  shoulder. 
These  would  draw  the  line  of  the  mouth  out  of  place  and  to  the  right. 

There  were  no  other  appreciable  involuntary  or  incoordinated  move- 
ments. This  young  man  was  skilful  with  his  hands  and  showed  no 
lack  of  strength.  He  was  psychically  normal  in  his  character.  He 
came  from  nervous  but  not  neuropathic  stock,  and  in  trying  to  find  any 
nervous  symptoms  in  the  family  we  had  to  go  back  to  a  great-aunt  who 
had  been  afflicted  with  tics.  It  was  just  this  possible  heredity  which  had 
disturbed  his  family,  and  which  had  led  them  to  dwell  upon  the  subject 
and  to  allow  our  patient  to  become  disturbed  more  than  there  was  any 
reason  for,  considering  how  slight  the  difficulty  was. 

As  a  matter  of  fact,  this  young  man  had  just  passed  two  years  in 
bed  for  a  coxalgia.  He  had  been  almost  continually  in  a  recumbent 
position  on  the  right  side,  with  his  head  leaning  on  that  arm.  In  this 
position  he  was  able  to  read.  As  it  was  very  difficult  for  him  to  make 
any  movement  (for  he  was  wearing  a  plaster  cast)  when  he  wished  to 
speak  to  the  attendant  who  was  always  with  him,  he  would  not  move, 
but  would  twist  his  face  a  little  to  the  right.  The  result  was  that  after 
a  time  there  was  a  slight  muscular  predominance  on  the  side  in  ques- 
tion, and,  when  he  was  examined  in  repose,  it  was  found  that  the  right 
labial  commissure  was  slightly  turned  upward.  For  the  same  reasons 
the  right  shoulder  was  found  to  be  a  little  lower  than  the  other,  as 
could  easily  be  seen  when  he  was  undressed. 

From  that  time  on,  the  movements  made  by  this  young  man  were 
movements  of  rectification  or  of  adjustment,  which  tried  to  raise  up 
the  fallen  shoulder  and  to  bring  back  the  twisted  axis  of  his  lips.  But 
his  family,  being  unduly  disturbed  by  the  symptoms,  kept  continually 
speaking  to  the  young  fellow  about  it;  the  movements  consequently 
became  more  frequent,  and  increased  daily,  even  hourly,  according  to 
the  degree  of  attention  which  was  brought  to  bear  upon  them.  The 
young  man,  being  noticed  so  much,  began  to  brood  over  his  trouble,  and, 
feeling  annoyed  by  the  discomfort  arising  from  his  trifling  deformity, 
he  instinctively  made  the  necessary  movements  to  overcome  it. 


136  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

It  seems  to  us  that  a  great  many  of  these  nervous  movements  so 
frequently  seen  in  youth  are  due  to  some  mechanism  of  this  kind.  They 
are  the  instinctive  correction  of  vicious  attitudes.  It  goes  without  say- 
ing that  to  call  attention  to  them  only  makes  them  worse. 

Perhaps  a  certain  number  of  hysterical  choreas  might  be  placed  with 
symptoms  of  this  kind,  which  become  more  or  less  diffused  according 
to  the  degree  of  attention  and  auto-suggestion  which  is  brought  to  bear 
upon  them. 

We  shall  not  dwell  any  longer  on  these  manifestations,  which  are 
important  only  in  so  far  as  they  are  considered  so.  They  often  disap- 
pear spontaneously  without  any  treatment.  Their  real  interest  lies 
chiefly  in  the  mistaken  diagnoses  which  are  frequently  based  upon  them. 
It  is  often  possible,  without  a  thorough  examination,  to  take  them  for 
the  starting-point  of  tics  or  hysterical  chorea,  and,  if  a  physician  does 
not  take  their  exact  nature  into  account,  he  may  commit  some  sruch 
therapeutic  error. 

4.  Contractures  and  Paralyses. — A  contracture  is  a  persistent  tonic 
and  involuntary  contraction  of  one  or  several  muscles  of  the  body. 
Paralysis  consists  of  the  more  or  less  complete  abolition  of  the  voluntary 
motor  power  (the  striated  muscles)  and  of  reflex  motor  activity  (smooth 
muscles). 

Functional  paralyses  and  contractures — that  is  to  say,  those  that 
have  no  relation  to  any  organic  lesion — are  met  with  chiefly  in  hysterics. 

We  shall  pass  rapidly  over  the  clinical  characteristics  of  hysterical 
paralyses  and  contractures.  The  paralysis  may  take  the  form  of  a 
hemiplegia,  monoplegia,  or  paraplegia.  It  is  frequently  associated  with 
superimposed  disturbances  of  sensibility.  The  symptoms  which  permit 
the  differentiation  of  these  paralyses  from  organic  paralyses  are  very 
well  known,  and  we  shall  not  dwell  upon  them.  One  point  only  seems 
to  us  of  interest  to  remember  (we  shall  see  why  in  a  moment),  and 
that  is  that  so  far  as  'the  face  is  concerned  one  much  more  frequently 
observes  a  glossolabial  spasm  than  a  facial  paralysis  properly  so  called. 

The  contracture  may  be  monomuscular,  may  affect  a  group  of  muscles, 
a  segment  of  a  limb,  one  limb,  or  several  limbs.  The  rigidity  may  be 
extreme  and  unyielding.  It  brings  about  deformities  which  are  some- 
times very  marked  and  which  are  rarely  met  with  in  other  contractures. 

The  condition  of  the  reflexes  in  contractures  and  in  hysterical 
paralyses  is  a  subject  still  under  discussion,  and  we  shall  take  up  the 
problem  further  on,  when  we  study  the  possible  modifications  of  the 
reflexes  in  the  course  of  a  psychoneurosis. 

Although  from  the  semiological  point  of  view  these  troubles  are 
well  classified,  and  have  definite  characteristics  which  everybody  admits, 
the  same  is  by  no  means  true  as  far  as  their  nature  and  pathogeny  are 
concerned.    'We  shall  find  in  studying  the  contractures  and  paralyses 


SYMPTOMS  IN  NEURO-MUSCULAR  APPARATUS.    137 

the  very  same  difficulties  in  their  interpretation  as  those  which  we  met 
when  we  were  studying  the  disturbances  of  sensibility. 

The  solution  which  Babinski  offers  is  extremely  simple,  and  is  in 
consequence  not  considered  so  attractive.  According  to  this  author, 
it  is  as  necessary  to  have  an  act  of  the  will  to  relax  a  muscle  as  it  is  to 
contract  it.  In  the  hysteric  this  voluntary  action  is  suspended,  the  re- 
sult being  a  paralysis  if  there  is  a  permanent  relaxation,  or  a  contracture 
if  a  persistent  contraction. 

This  is  the  hypothesis,  but  do  the  facts  bear  it  out?  First  of  all, 
parenthetically,  we  would  like  to  throw  some  light  on  the  connection 
which  is  often  found  (we  do  not  say  that  it  is  always  the  case)  between 
contractures  and  paralyses.  How  is  contracture  brought  about  in 
organic  paralyses?  In  the  great  majority  of  cases  it  is  caused  by  a 
predominance  of  the  extensor  muscle  activity  in  the  lower  limbs  and  of 
the  flexors  in  the  arms.  We  do  not,  as  a  matter  of  fact,  believe — and 
one  of  us  has  already,  in  1900,  made  this  point  clear — ^that  organic  con- 
tractures may  be  explained  by  the  existence  of  paralyses  of  certain 
muscles  mth  a  hypertonia  of  others.  Here,  as  a  matter  of  fact,  the  position 
of  the  limbs  is  the  same  as  that  seen  in  tetanus  or  in  strychnine  poison- 
ing— namely,  flexion  in  the  upper  limbs  and  extension  in  the  lower. 
In  other  words,  in  hémiplégie  contractures  of  organic  origin  the  limbs 
take  the  position  which  is  imposed  upon  them  by  the  **  resultant  of  the 
antagonistic  forces  of  the  muscles  in  a  state  of  hypertonicity  "  (De- 
jerine).  But  in  hysterical  contractures  the  position  of  the  limb  in  the 
majority  of  cases  is  the  same  as  in  organic  contractures.  In  other 
words,  in  the  hysterical  hémiplégie  or  paraplegic  all  the  muscles  share 
in  the  contracture,  as  in  the  case  of  organic  lesions.  This  is,  however, 
not  always  the  case  and  in  hysterics  one  may  observe  contractures  which 
fix  the  limbs  in  a  position  other  than  that  resulting  from  muscular 
predominance,  and  this  occurs  under  certain  special  conditions,  as  we 
shall  see  immediately. 

With  this  parenthesis,  the  first  question  which  we  should  ask  our- 
selves is  the  following.  On  what  occasion  did  the  hysterical  paralyses 
and  contractures  appear?  The  predominant  etiological  circumstance 
is  undoubtedly  emotion.  The  latter  (and  it  is  an  important  fact)  may 
act  very  suddenly,  leaving  the  patient  paralyzed  or  contracted  all  at 
once,  without  his  even  having  had  time  to  know  it.  In  a  recent  dis- 
cussion of  the  Neurolpgical  Society, — ^December,  1909, — several  facts 
of  this  kind  were  reported.  One  of  us,  in  particular,  reported  several. 
The  most  convincing  perhaps  concerned  a  woman  of  the  people,  who 
was  without  education  or  instruction,  having  always  lived  in  her  own 
environment  and  being  wholly  ignorant  that  any  such  thing  as  hysterical 
contracture  existed.  Up  to  the  time  of  her  accident  she  had  never  shown 
the  slightest  neuropathic  phenomenon.  One  day  while  she  was  very 
carefully  preparing  a  meal,  this  cabn  and  placid  woman  fell  into  a 
violent  rage  with  her  husband.    She  worked  herself  up  into  an  intense 


138  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

state  of  emotion.  Her  husband  sneered  at  her,  and  she  tried  to  box 
his  ears.  But  at  that  very  instant  the  upper  part  of  her  right  arm 
was  seized  with  a  contracture.  We  could  mention  several  cases  of 
paralysis  which  have  been  produced  under  like  circumstances.  One 
fact,  therefore,  is  certain, — that  an  emotion,  of  itself,  and  without  any 
suggestive  intervention  or  any  voluntary  participation  on  the  part  of 
the  patient,  may  suddenly  create  contractures  and  paralyses. 

A  second  question,  whose  solution  would  be  rich  in  theoretical  re- 
sults, has  to  do  with  the  persistence  of  hysterical  paralyses  and  con- 
tractures during  sleep.  The  discussion  of  the  Paris  Neurological  Society, 
in  May,  1908,  on  hysteria,  considered  this  question  of  contractures  dur- 
ing sleep  alone.  It  would  be  interesting  to  know  whether  hysterical 
hémiplégies  settle  themselves  down  comfortably  to  sleep,  and  whether 
they  are  able  to  modify  their  positions  during  sleep.  So  far  as  the 
contractures  are  concerned,  very  contrary  opinions  were  held.  Babinski 
denied  the  persistence  of  contractures,  while  Eaymond  affirmed  them. 
As  a  matter  of  fact,  it  is  extremely  difficult  to  learn  the  facts  about 
such  things.  Hysterical  individuals  are  apt  to  sleep  "with  one  eye 
open,"  and  one  can  hardly  examine  them  without  waking  them.  One 
fact,  however,  seems  to  be  of  value.  If  an  hysterical  contracture  is 
relaxed  during  sleep,  how  can  one  explain  the  existence  in  certain  of 
these  patients  of  fibrous  adhesions  which  sometimes  cannot  be  overcome 
even  with  the  use  of  chloroform  ?  We  have  seen  one  patient  of  this  kind 
who  had  had  contractures  in  three  limbs  for  some  years,  and  in  whom 
there  was  every  evidence  of  periarticular  fibrous  adhesions,  which  still 
persist,  even  though  all  signs  of  contracture  have  long  since  disappeared. 
If,  in  the  case  of  this  woman,  the  contractures  had  disappeared  during  sleep 
for,  say,  eight  to  ten  hours  out  of  the  twenty-four,  it  is  not  very  likely 
that  these  anatomical  changes  would  have  taken  place.  We  have  seen  a 
similar  case  of  a  double  contracture  of  the  adductors,  dating  back  for 
four  years,  as  a  result  of  an  attempted  violation,  in  which  there  existed 
fibromuscular  adhesions  which  were  very  difficult  to  break  up  under  the 
influence  of  chloroform. 

Hysterical  contractures  and  paralyses,  Babinski  said,  are  made  and 
unmade  at  will  under  the  influence  of  suggestion.  We  feel  that  some 
distinction  should  be  made  in  the  cases.  There  are  two  forms  of  hysteria. 
There  is  cultivated  hysteria  such  as  was  formerly  seen  at  the  Salpêtrière, 
and  there  is  real  non-educated  hysteria.  Without  any  possible  question, 
Babinski 's  ideas  apply  to  patients  of  the  first  group.  In  those  cases,  as 
a  matter  of  fact,  with  the  more  or  less  conscious  connivance  of  the 
patients,  one  can  get  almost  anything  out  of  them  that  one  wants.  It 
was  an  hysteric,  you  may  remember,  one  of  the  stand-bys  of  the  hos- 
pital frequenting  the  general  medical  wards,  who,  when  they  wanted 
to  make  him  sign  his  dismissal  card,  said  to  one  of  us,  "But,  sir,  I  can 
have  a  hemiplegia,  or  a  hemianassthesia,  or  a  contracture,  whatever  you 
will.     Am  I  not  an  interesting  patient?"     The  mythomania  of  this 


SYMPTOMS  IN  NEURO-MUSCULAR  APPARATUS.    139 

class  of  patients,  their  dramatic  instinct,  and  often  their  practical  in- 
terest as  well,  make  them  lend  themselves  very  readily  to  the  most 
diverse  suggestions.  This  applies  to  professional  hysteria  which  under- 
stands its  duties,  its  advantages,  and  also  its  slight  inconveniences. 
This  discussion  has  nothing  to  do  with  these  patients.  The  case  is  not 
the  same  with  accidental  hysterics,  who  are  very  often  honest  people, 
and  who  are  quite  properly  disgusted  when  on  being  seized  with  a 
paralysis  or  a  contracture  they  find  themselves  considered  to  be  more 
or  less  simulators.  With  these  patients  it  is  much  more  difficult  to 
make  the  symptoms  appear  or  disappear  rapidly.  'One  sees  hemiplegias 
and  contractures  persisting  sometimes  for  a  very  long  time  in  spite  of 
all  suggestions.  As  far  as  the  production  of  paralyses  or  contractures 
in  hysterics  by  direct  suggestion  goes,  we  ought  in  truth  to  say  that,  as 
that  is  contrary  to  our  therapeutic  method,  we  have  personally  never 
made  any  attempts  along  this  line.  We  are,  therefore,  obliged  to  refer 
to  authors  who,  like  P.  Janet,  have  stated  that  it  was  very  difficult  and 
generally  quite  impossible  to  produce  lasting  paralyses  or  contractures 
by  suggestion. 

Babinski  draws  another  argument  from  the  actually  far  greater  in- 
frequency  of  hysterical  paralyses  and  contractures  in  comparison  with 
what  one  used  to  see  formerly.  As  a  matter  of  fact,  it  is  very  evident, 
after  what  he  has  just  said,  that  all  the  manifestations  of  cultivated 
hysteria  have  disappeared,  reducing  the  frequency  of  such  manifesta- 
tions to  its  just  proportions.  It  is  none  the  less  true  that,  speaking 
only  of  hospital  practice,  one  of  us  still  treats  each  year  in  the 
Salpêtrière  service  a  rather  large  number  of  paralyses  and  contractures 
of  hysterical  origin.  This,  however,  is  a  purely  negative  argument,  and 
cannot  be  considered  as  favoring  one  conception  more  than  another. 

Our  personal  conviction  is,  therefore,  that  there  exist  hysterical  con- 
tractures which  are  true  contractures,  coming  within  the  definition  that 
we  have  just  given, — ^that  is  to  say,  which  are  at  the  same  time  perma- 
nent and  involuntary.  We  also  believe  that  there  exist  troubles  by 
non-intentional  suppression  of  the  voluntary  motor  powers,  and  which  are 
hysterical  paralyses.  The  same  phenomena  which  an  emotion  may  call 
forth  transiently  may  be  rendered  lasting  by  an  hysteria.  For  we 
frequently  see  emotion  leading  up  to  pseudoparalj^iç  manifestations, 
such  as  the  giving  way  of  the  legs,  the  impression  of  being  about  to 
sink  to  the  ground,  etc.    *' Emotion  takes  one  by  the  arms  and  legs.'' 

But  here,  as  for  hemianaesthesia,  we  will  very  willingly  admit  the 
secondary  intervention  of  mental  representation.  It  is  the  very  nature 
of  hysteria  to  fix,  in  the  individual,  sensations  or  conditions  which  would 
normally  be  transient,  and  it  is  quite  probable  that,  secondarily  to  the 
emotional  phenomena,  the  hysteric  is  psychically  convinced  of  his  help- 
lessness, and  cannot  get  hold  of  himself  physically.  This  is  how  the 
systematization  of  the  paralyses  or  hysterical  contractures  comes  about, 


140  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

as  a  result  of  the  fixing  of  some  set  of  mental  representations  upon  a 
functional  muscular  group  or  a  segment  of  a  limb  or  a  part  of  the  body. 

Other  contractures  seem  to  us  to  have  a  wholly  different  origin. 
They  are  what  might  be  called  contractures  of  defence.  Here,  for 
example,  is  a  woman  on  whom  rape  has  been  attempted,  or  one  who  is 
attacked  by  vaginismus,  which  has  brought  on  a  contracture  of  the 
adductors.  Here  is  an  individual  who  has  added  an  hysterical  con- 
itracture  to  a  more  or  less  painful  joint.  It  would  seem  to  us  that  we 
have  here  a  case  of  immobilization  in  the  position  of  defence  against  the 
rape  or  against  the  pain.  These  patients,  on  the  other  hand,  although 
they  may  have  often  shown  themselves  indifferent  to  the  symptoms,  are 
very  far  from  being  indifferent  to  its  cause.  They  think  about  it  the 
whole  time.  They  are  sometimes  literally  obsessed  by  what  they  have 
had  to  go  through,  or  by  the  painful  symptoms  of  which  they  are 
the  prey.  The  persistence  of  their  contractures  is,  in  fact,  merely  the 
objective  manifestation  of  the  persistence  in  their  psychism  of  the 
creative  cause  itself.  These  are  in  a  certain  sense  phobic  manifestations. 
When  we  call  an  act  to  mind  we  visualize  the  movements  which  produced 
it.  Contractures,  in  fact,  persist  because  the  patients  continue  to 
defend  themselves  in  thought.  On  the  other  hand,  treatment  shows 
the  reality  of  such  a  conception,  for  the  patients  are  only  cured  when 
they  cease  to  be  afraid,  when  they  are  no  longer  in  the  slightest  degree 
influenced  by  the  impression  which  gave  rise  to  the  symptoms.  It  is 
quite  possible  that  the  contracture  may  be  variable  in  such  cases  and  that 
it  may  cease  during  sleep,  but  these  patients  sleep  very  little.  Again, 
we  must  add  that  not  all  such  contractures  are  due  to  hysteria,  and 
that  even  in  those  patients  who  have  true  hysterical  contractures  they 
do  not  try  to  manufacture  their  symptoms  nor  are  they  aware  that 
these  are  due  to  hysteria. 

We  have  now  finished  with  the  functional  fixations  which  affect  thé 
muscular  apparatus.  This  chapter,  although  containing  so  many  ramifi- 
cations, is  nevertheless  only  too  incomplete,  and  during  the  course  of 
our  later  descriptions  we  shall  meet  with  a  whole  series  of  disturbances 
which  we  have  omitted  here  because  the  neuro-muscular  apparatus  is 
not  the  only  one  that  comes  into  play  and  because  they  are  better 
classified  elsewhere. 


CHAPTER  VIII. 

DIFFUSE  OR  LOCALIZED  DISTURBANCES  OF  SENSIBILITY. 

First  of  all,  how  does  general  sensibility  behave  under  an  emotion? 
Two  distinct  classes  of  facts  and  of  wholly  different  mechanism  may  be 
observed. 

If  it  is  a  question  of  intense  and  prolonged  emotion,  without  mental 
representations  or  without  the  anxious  waiting  for  some  painful  phenom- 
enon to  appear,  general  sensibility  may  be  completely  deadened.  The 
subject  is  totally  anaesthetic.  This  may  occur  equally  under  the  effect 
of  emotions  which  are  called  sthenic  as  well  as  under  those  which  are 
depressive. 

A  soldier  on  the  field  of  battle,  a  man  rushing  to  a  rescue  in  a 
fire,  may  be  wounded  without  even  perceiving  it.  In  the  same  way 
in  a  railroad  accident,  or  in  an  earthquake,  sensibility  may  completely 
disappear,  and  individuals  who  are  seriously  hurt  may  be  seen  wander- 
ing distractedly  over  the  scene  of  disaster  without  taking  any  notice 
of  the  injuries  which  they  have  suffered.  Such  facts  are  classic  ;  history 
furnishes  many  examples  of  them. 

The  mystic  uplift  of  the  mind,  or  religious  emotion,  if  one  so  prefers 
to  call  it,  is  able  to  bring  about  the  same  effect.  The  history  of  the  martyrs 
is  full  of  stories  of  individuals  who  have  undergone  the  direst  suffering 
without  showing  any  signs  of  pain.  It  is  a  very  different  matter,  on  the 
other  hand,  when  people  are  expecting  something  which  will  give  them 
pain.  In  these  cases  the  phenomena  of  sensibility  receive,  on  the  con- 
trary, a  psychic  reinforcement.  It  even  happens  that  individuals  will 
have  the  impression  of  pain  before  the  thing  which  will  give  them  pain 
has  touched  them.  This  is  the  case  with  the  patient  who  screams  before 
she  is  touched  ;  and,  although  this  cry  is  often  called  forth  by  fear,  yet 
it  is  also  often  true  that  a  mental  representation  alone  will  be  enough 
to  make  her  feel  a  painful  sensation  which  she  believes  to  be  distinctly 
localized. 

Moreover,  under  these  conditions  real  pain  is  peculiarly  reinforced. 
A  simple  touch  may  become  extremely  painful,  which  without  this 
emotional  expectancy  of  pain  would  scarcely  be  perceived. 

These  hyperaesthesias  may  be  diffused  or  localized  according  as  the 
subject  is  uncertain  of  the  point  where  he  ought  to  feel  the  painful 
sensation  or  as  he  is  forewarned  and  has  fixed  his  mind  upon  the  prob- 
able region  of  the  pain.  Under  these  last  conditions  localized  hyper- 
aesthesia  may  be  accompanied  by  a  total  or  relative  anaesthesia  of  other 
regions.  This  is  a  fact  that  is  well  known  to  operators,  especially  to 
dentists,  who  fix  the  attention  of  their  patients  on  one  point  while  they 
are  operating  without  pain,  or  with  very  little,  on  some  other  point. 

141 


142  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

Under  these  circumstances  it  is  not  a  question  of  a  pure  and  simple 
emotion.  The  pain  is  not  caused  by  an  emotional  shock,  nor  is  it  due 
to  a  more  or  less  continuous  emotional  condition.  The  emotion  here  is 
complicated  with  expectancy,  which  is  a  psychic  phenomenon,  and  we 
are  quite  ready  to  believe  that  hypersesthesias  are  often  really  phenomena 
of  suggestion,  the  emotion  coming  in  as  a  factor  of  suggestibility. 

But,  acting  directly  and  without  the  intervention  of  anything  that 
would  cause  pain,  continued  emotion  may  bring  about  a  state  which,  if 
not  that  of  hyperassthesia,  is  at  least  one  of  hyperexcitability,  in  the 
course  of  which  all  contacts  are  painful  and  accompanied  by  sharp 
reactions,  a  state  of  hyperexcitability  which  in  certain  cases  may  very 
distinctly  demonstrate  the  exaggeration  of  the  reflexes. 

It  is  very  evident  that  all  these  phenomena  concerning  general  sensi- 
bility are,  properly  speaking,  purely  central  phenomena.  The  skin  only 
comes  into  question  as  being  the  part  that  is  touched.  It  has  seemed  to 
us,  nevertheless,  that  these  troubles,  like  those  that  we  have  already 
described,  ought  to  be  studied  according  to  their  subjective  localization. 
It  is  none  the  less  true  that  general  sensibility  is  not  confined  to  the 
skin  alone.  Certain  mucous  membranes  share  in  it.  The  connective 
tissue,  muscles,  and  bones  are  subject  to  it,  and  what  we  have  just  said 
of  disturbances  of  sensibility  which  are  emotional  in  origin  may  be 
very  naturally  applied  not  only  to  the  cutaneous  sensibility,  but  also 
to  all  the  points  of  the  body  on  which  any  traumatic  action  whatsoever 
is  liable  to  cause  a  mental  representation  of  pain. 

One  objection  might  be  raised  resulting  from  the  fact  that  under 
certain  conditions  we  have  considered  expectation  as  an  emotional 
phenomenon.  It  is  very  certain  that  at  the  first  glance  expectation 
would  appear,  on  the  contrary,  to  be  a  phenomenon  of  reason.  Then, 
too,  expectation  alone  is  not  enough  to  create  those  phenomena  of  psychic 
reinforcement  of  pain  of  which  we  have  spoken.  When  expectation  is 
reflective,  cold  as  it  were,  it  does  not  increase  pain;  it  even  enables  one 
by  the  intervention  of  the  will  to  suppress  any  outer  sign  of  it.  But 
let  the  attention  in  an  impressionable  subject  be  mixed  with  emotional 
elements  or  phobic  elements,  and  the  pain  will  be  reinforced.  This  is 
exactly  where  the  interesting  theoretical  point  comes  in.  It  lies  in  the 
rôle  that  emotion  will  play, — viz.,  the  rôle  of  emotional  mental  repre- 
sentation of  which  we  have  already  spoken,  and  which  we  shall  come 
across  again  and  shall  develop  at  length,  when,  after  finishing  the 
analytic  part,  we  shall  reach  the  synthetic  study  of  functional 
localizations. 

The  rôle  which  emotion  plays  is  no  less  distinct  in  the  production 
of  subjective  disturbances  of  sensibility.  We  know  that  emotion  very 
frequently  produces  phenomena  of  cœnassthesia.  Sensations  of  thoracic 
tension,  impressions  of  painful  contractions  of  the  abdomen,  painful 
genital  or  perigenital  sensations,  may,  however,  be  produced  just  as 
well  by  an  emotional  shock  as  by  a  subcontinuous  emotional  préoccupa- 


DISTUEBANCES  OF  SENSIBILITY.  143 

tion.  Our  very  decided  impression,  which  is  drawn  from  a  great  number 
of  clinical  facts,  is  that  many  of  the  profound  persistent  pains  which 
are  met  with  in  neurasthenics,  and  which  are  described  by  the  name 
of  algias,  have  no  other  origin. 

As  a  matter  of  fact,  disturbances  of  cutaneous  sensibility  in  the 
course  of  the  psychoneuroses  are  of  two  kinds.  They  may  consist  of 
purely  subjective  disturbances  or  of  disturbances  which  are  easily 
proved  to  be  objective.  The  latter  themselves  include  two  varieties. 
Sometimes  they  have  to  do  with  phenomena  of  anaesthesia,  sometimes  it 
is  a  question  of  hyperesthesia. 

We  must,  therefore,  take  up  successively  : 

A.  Objective  disturbances  of  cutaneous  sensibility:  (a)  Anœsthesia, 
(&)  hyperœstJiesia. 

B.  Subjective  disturbances  of  sensibility. 

A.  Objective  Disturbances  of  Cutaneous  Sensibility. — (a)  Anœs- 
thesia. — The  anesthetic  disturbances  which  we  have  been  able  to  observe 
in  the  course  of  the  psychoneuroses  are  numerous.  In  a  general  way 
they  include  at  one  and  the  same  time  all  forms  of  sensibility, — tactile, 
thermal,  pain,  and  even  deep  sensibility.  Also,  as  a  general  thing,  they 
are  classified  among  the  hysterical  symptoms,  and  it  is  very  rare  that 
anassthetic  objective  disturbances  of  sensibility  are  met  with  in  neuras- 
thenics. The  topography  of  this  class  of  disturbances  rests  on  classic 
findings. >■  Its  essential  characteristic  is  what  we  might  call  its  geometric 
limitations.  These  hysterical  ansesthesias  appear  band-like,  as  a  pair 
of  cuffs,  or  occupying  a  region  covered  by  the  trousers  or  the  socks. 
Their  name  indicates  that  they  attack  a  limb  or  a  portion  of  a  limb, 
and  that  their  upper  and  lower  boundaries  are  distinctly  determined 
by  a  circle.  On  the  trunk  they  may  appear  as  anaesthetic  spots,  or 
limited  areas  of  anaesthesia. 

But  of  all  the  anesthetic  manifestations  which  hysteria  may  create, 
the  one  which  is  considered  the  commonest  is  undoubtedly  hemianes- 
thesia. This  hemianesthesia — which  fetters  not  only  general  sensibility 
but  still  further  special  sensibilities,  which  is  often,  to  employ  the  classic 
expression,  sensorially  sensitive — strikes  exactly  one  half  of  the  body 
and  leaves  the  other  half  strictly  alone.  As  a  rule,  it  attacks  the  left 
side.  As  is  the  case  with  all  hysterical  troubles,  it  is  much  more  fre- 
quent in  women  than  in  men. 

The  very  existence  of  this  hemianesthesia,  as  far  as  hysterical  stig- 
mata are  concerned,  has  been  called  into  question  by  some  authors, 
Bemheim  first  of  all,  and  then  Babinski,  who  is  the  chief  one  to  stand 
out  against  it,  as  well  as  against  the  segmentary  anesthesias. 

According  to  this  author,  the  hemianesthesia  would  be  due  either  to 
a  medical  suggestion  or  to  an  auto-suggestion  by  imitation.  Patients 
who  have  seen  other  subjects  examined  for  this  hemianesthesia,  and 


144  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

its  existence  established,  are  persuaded  that  they  ought  to  show  the 
same  symptom.  From  that  time  on,  if  they  do  not  feel,  it  is  because 
they  do  not  wish  to  feel.  But  here  we  must  explain  ourselves,  for  the 
question  is  singularly  complex. 

If  we  could  but  find  a  subject  in  whom  suggestion  had  suddenly 
produced  a  hemianagsthesia,  everybody  would  be  convinced.  It  would 
unquestionably  be  an  hysterical  symptom.  Babinski  would  call  it  ''a 
pithiatic  symptom";  but  the  word  has  nothing  to  do  with  the  thing, 
and  this  author  would  be  the  first  to  recognize  the  fact  that  such  symp- 
toms are  found  only  in  those  individuals  who  were  formerly  called 
and  who,  except  by  Babinski  and  those  who  follow  him,  are  still  called 
hysterics. 

There  is  consequently  no  doubt  that,  whatever  may  be  their  origin, 
hemianassthesiae  as  well  as  segmentary  angesthesiae  are  hysterical  stigmata. 
But  this  is  not  the  question  under  discussion. 

The  important  thing  is  to  know  whether,  in  certain  individuals, 
under  the  influence  of  emotions  or  of  emotional  representations,  or  some 
other  mechanism,  and  outside  of  the  conscious  intervention  of  the  will 
of  the  subject,  disturbances  of  sensibility  with  definite  topographical 
hmitations  are  liable  to  be  created.  The  question,  in  other  words,  is 
whether  the  subject  who  cannot  feel  anything  simulates  his  anaesthesia 
or  really  does  not  experience  any  painful  impression.  For,  if  we  admit 
that  under  the  influence  of  even  a  direct  suggestion  sensibility  may  really 
disappear,  the  whole  theory  falls  to  the  ground.  As  a  matter  of  fact, 
it  would  really  be  strange  if  a  rather  vivid  emotion  or  a  personal  direc- 
tion of  the  mentality  of  the  subject  could  not  produce  the  same  effect 
as  that  brought  about  by  a  suggestion,  which  is  after  all  an  indifferent 
element,  and  one  would  be  led  to  conceive  that  the  disturbance  of  sensi- 
bility in  hysterical  individuals  might  in  truth  be  brought  out  by  sug- 
gestions, but  with  very  much  more  reason  by  any  psychic  traumatism 
whatever  that  was  able  to  create  them. 

Hence  the  prejudicial  questions  which  it  seems  to  be  our  duty  to 
solve  are  the  following:  Can  the  hysterical  individual  who  is  in  a  state 
of  apparent  anaesthesia  really  feel  anything?  Is  the  anaesthesia  always 
a  phenomenon  of  suggestion?  Where  does  the  break  come  in  that 
causes  the  non-transmission  of  the  peripheral  stimulus  to  the  superior 
centres  ? 

Can  the  hysteric  who  is  in  a  state  of  apparent  anaesthesia  really  feel 
anything?  It  is  quite  evident  that  as  far  as  tactile  sensibility  is  con- 
cerned the  problem  can  never  be  solved.  A  simulator  can  always  say 
that  he  does  not  feel  what  he  touches,  even  though  the  stimulus  may 
have  been  transmitted  and  recognized.  As  far  as  this  mode  of  sensi- 
bility is  concerned,  one  could  fall  back  upon  the  fact  of  non-attention. 
In  order  to  feel  impressions  as  slight  as  those  produced  by  simple  con- 
tact, it  is  evident  that  the  subject  must  try  to  pay  attention  as  to 
whether  he  feels  them  or  not,  and,  if  voluntarily  he  turns  his  attention 


DISTURBANCES  OP  SENSIBILITY.  145 

away  and  fixes  it  upon  something  else,  it  is  possible  that  the  slight 
tactile  impression  may  not  be  felt,  by  a  simulation  which  is  unconscious 
in  a  way,  but  which  would  none  the  less  enter  into  Babinski's  con- 
ceptions. We  must  also  add  that  in  reality  the  subject  will,  on  the 
contrary,  almost  always  have  his  attention  drawn  to  this  sensibility  by 
the  very  circumstances  of  the  examination.  He  will  consequently  be  in 
that  condition  which  would  lead  a  normal  subject  to  perceive  contacts 
which  he  would  not  feel  in  daily  life,  psychically  speaking.  And,  on 
the  other  hand,  in  the  clinic  it  generally  appears  that  disturbances  of 
sensibility  in  an  hysteric  are  in  direct  proportion  to  the  attention  which 
the  subject  brings  to  bear  upon  them,  and  that  they  diminish  when  the 
attention  is  turned  away. 

There  is,  however,  one  mode  of  contact  which  is  apt  to  produce  very 
decided  impressions.  We  refer  to  tickling,  which  in  certain  individuals 
provokes  extremely  violent  reactions  which  the  will  is  wholly  incapable 
of  stopping.  How,  then,  can  it  be  possible  for  one  to  tickle  the  sole 
of  the  left  foot,  for  example,  of  an  hysteric,  with  impunity,  without 
calling  forth  the  slightest  reaction,  when  the  same  thing  on  the  right 
foot  will  bring  about  an  extreme  reaction  which  the  will  is  powerless 
to  inhibit?  This  is  a  disturbing  fact,  and  one  which  would  suppose  a 
very  peculiar  strength  in  the  will  of  the  simulator.  We  shall  come 
back,  however,  to  this  point  when  we  study  the  cutaneous  reflexes  in 
hysteria. 

However  it  may  be,  do  not  let  us  come  to  any  conclusion  and  let  us 
admit  that  the  problem  so  far  as  tactile  sensibility  is  concerned  may  be  in- 
soluble. As  regards  thermal  and  pain  sensibility  the  case  is  not  the  same. 
The  fact  is  that  one  may  lay  very  hot  bodies  upon  the  skin  of  hemian- 
œsthesic  hysterics,  and  that  one  may  pinch  them  violently  and  even  stick 
pins  in  them,  without  their  showing  that  they  feel  the  slightest  sensation. 
In  certain  cases  of  hemi anaesthesia  in  men,  one  of  us  has  been  able  to 
apply  excessive  pressure  on  the  testicle  of  the  ansesthesic  side  without 
the  patient  giving  any  sign  of  noticing  it.  Of  course  the  simple  state- 
ment of  a  patient  is  not  enough  to  convince  one.  It  is  true  that  one 
can  by  the  will  suppress  part  of  the  customary  reactions  to  pain.  One 
can  keep  from  crying  out.  One  can  in  a  certain  measure  involuntarily 
inhibit  a  part  of  the  reactions  of  defence  which  pain  usually  brings 
about.  But  can  one  inhibit  all  of  them  ?  Can  one  prevent  that  instinctive 
shrinking  which  so  generally  occurs?  Above  all,  can  one  prevent  those 
vasomotor  phenomena — ^the  flushing  or  paling  of  the  skin,  for  example, 
the  contraction  of  the  brow,  the  narrowing  of  the  palpebral  fissure,  etc. — 
which  follow  states  of  sharp  pain?  This  seems  to  us  doubtful  at  the 
least.  Nevertheless,  these  phenomena  are  not  produced  in  hysterical 
individuals,  and,  further,  there  has  been  seen,  in  a  certain  number  of 
cases,  the  absence  of  local  reactions,  such  as  a  flow  of  blood  after  a 
prick  or  ecchymosis  after  pinching. 

The  great  argument  in  favor  of  the  theory  of  simulation  lies  in  the 
10 


146  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

fact  that  hysterical  individuals  are  rarely  afflicted  with  involuntary 
traumatisms.  In  anaesthesias  due  to  some  organic  cause,  in  syringo- 
myelia, hgematomyelia,  and  anaesthetic  leprosy  among  others,  it  very 
frequently  occurs,  and  it  often  happens  that  the  anaesthesia  is  noticed 
for  the  first  time  when  the  patients  burn  themselves  without  perceiving 
it.  But  this  peculiarity  is  rather  rare  in  these  affections,  for  in  hemian- 
œsthesiae  by  cerebral  lesions  and  in  the  anaesthesiae  of  tabetics  it  is  only 
occasionally  found. 

Among  hysterical  individuals  the  phenomenon  is  very  rare,  because, 
it  is  said,  these  patients  know  very  well  how  to  guard  themselves  from 
contact  with  anything  that  is  too  hot,  which  means  that  they  are  warned 
by  the  heat  of  a  body, — in  other  words,  they  can  feel.  The  argument 
has  its  value,  but  does  not  seem  to  us  final. 

In  the  first  place,  as  a  matter  of  fact,  although  it  is  rare  for  an 
hysterical  individual  to  be  burned  without  feeling  it,  it  is  nevertheless 
not  an  absolutely  exceptional  fact,  and  we  have  had  examples  of  it  in 
patients  to  whom  the  thing  really  happened.  But,  on  the  other  hand, 
as  hysterical  hemianaesthesia  occurs  on  the  left  side  in  the  greater  number 
of  cases,  it  is  evident  that  accidents  of  this  kind  would  not  be  apt  to 
happen  as  often  as  in  the  cases  where  it  is  bilateral  or  when  the  right 
side  was  affected.  Finally,  it  is  very  certain  that  from  the  point. of 
view  of  pathophysiology  psychic  anaesthesia  does  not  perhaps  act  in  quite 
the  same  way  as  organic  anaesthesia.  This  is  a  question  which  we  shall 
take  up  again  very  soon. 

However  it  may  be  in  the  presence  of  a  case  where  the  pain  leads 
to  no  reaction,  and  in  the  presence  of  the  actual  facts  of  involuntary 
traumatisms,  we  cannot  help  but  admit  that  hysterical  anaesthesiae  seem 
to  behave  very  much  like  real  anaesthesiae.  It  is  very  certain  that  the 
partisans  of  simulation  could  always  uphold  their  opinion,  and  one 
would  never  be  able  absolutely  to  prove  to  them  that  a  subject  was  not 
simulating;  but  it  would  be  necessary  in  such  cases  for  the  simulators 
to  be  very  strong  and  very  much  on  their  guard.  Nevertheless,  there 
exist  cases  of  anaesthesia  which  have  developed  from  the  start  in  patients 
so  young  or  so  slightly  educated  as  to  make  such  a  knowledge  of  simula- 
tion seem  truly  extraordinary  to  us.  Still  another  argument  of  the  same 
psychological  order  seems  to  us  to  have  some  value.  This  is  the  fact 
that  it  is  extremely  rare  for  hysterical  individuals  to  complain  of  their 
anaesthesia.  They  are  much  more  apt  to  tell  one  that  their  arm  or  their 
leg  has  a  feeling  of  heaviness  in  it.  They  do  not  make  the  slightest 
mention  of  their  analgesia  or  their  thermoanaesthesia.  How  under  these 
conditions  could  they  even  get  the  idea  of  simulation  ? 

These  last  considerations  bring  us  to  the  second  question  :  Is  hysterical 
anaesthesia  always  a  phenomenon  of  suggestion?  In  this  theory  it  is 
claimed  that  hysterical  anaesthesiae  are  simulated  under  the  influence  of 
divers  suggestions.  We  have  just  seen  why  we  do  not  believe  that  they 
are  either  always  or  even  very  often  simulated.     We  do  not  believe 


DISTURBANCES  OF  SENSIBILITY.  147 

either  that  they  are  always  due  to  suggestion,  at  least — and  of  this  we 
are  very  positive — as  far  as  their  first  manifestation  is  concerned. 

Medical  suggestion,  or  suggestion  by  imitation,  is  what  the  holders 
of  this  theory  call  it:  As  far  as  suggestion  by  imitation  is  concerned,  it 
appears,  if  one  refers  to  the  discussions  which  took  place  in  1909  at  the 
Neurological  Society  of  Paris,  that  a  certain  number  of  neurologists, 
including  one  of  us,  were  in  a  position  to  affirm  that  they  had  had 
experience  with  hemianassthesias  occurring  in  patients  who  had  never 
had  anything  to  do  with  hysterics.  On  the  other  h^nd,  the  very  special 
topography  of  these  anaesthesiae,  whether  they  were  segmentary  anges- 
thesiae  or  hemianaesthesiae,  eliminated  all  idea  of  extra-medical  suggestion. 
As  a  matter  of  fact,  one  knows  that  the  limits  of  hysterical  ansesthesige 
are  absolutely  regular,  particularly  in  hemianaesthesiae.  Therefore,  we 
defy  anyone  w^homsoever  to  be  tested  in  those  regions  where  the  circles 
of  Weber  are  rather  large  and  to  indicate  exactly,  within  one  or  two 
centimetres  at  least,  the  superior  and  inferior  boundaries,  or  to  tell 
exactly,  we  repeat,  where  the  pincers  or  the  pin  which  is  used  in 
exploring  the  sensibility  crosses  the  median  line.  As  one  cannot  volun- 
tarily exactly  locate  the  median  line,  no  matter  how  keenly  one  pays 
attention,  how  can  phenomena  of  auto-suggestion  by  imitation,  while  at 
the  same  time  creating  anaesthesia,  endow  these  patients  with  such  a 
specialized  sensibility  that  they  are  able  to  have  more  precise  ideas  of 
their  cutaneous  topography  than  when  in  a  normal  condition  ? 

On  the  other  hand,  suggestion  by  imitation  is,  properly  speaking, 
only  a  form  of  simulation.  Suggestion,  by  its  very  definition,  means 
the  involuntary  introduction  into  the  mentality  of  the  subject  of  phenom- 
ena which  were  previously  strangers  to  him,  and  whose  acquisition  has 
no  reasonable  cause. 

If,  therefore,  the  phenomena  of  hysterical  anaesthesia  were  always 
phenomena  of  suggestion,  there  would  always  be  also  phenomena  of 
medical  suggestion.  One  would  then  have  to  start  examinations  of  the 
course  by  which  a  veritable  education  of  the  sensibilities  is  produced 
which  could  give  rise  to  the  precise  topography  of  these  disturbances. 

That  medical  suggestion  is  exercised  in  a  great  number  of  cases, 
and  particularly  in  those  hysterical  individuals  who  have  had  some 
little  training,  is  a  fact  that  cannot  be  doubted.  But  it  seems  to  us 
to  be  going  too  far  to  generalize  and  think  that  all  the  examinations  of 
sensibility  which  have  been  made  up  to  the  present  have  been  vitiated 
by  suggestive  elements  acting  as  much  on  the  subject  as  on  the  observer. 

To  show  the  rôle  which  medical  suggestion  can  play,  a  rôle  which  in 
certain  cases  we  do  not  try  to  deny,  different  arguments  have  been 
brought  to  bear.  First  of  all,  it  has  been  claimed  that  the  frequency  of 
anaesthesia  on  the  left  is  due  to  the  fact  that,  the  observer  examining 
with  the  right  hand,  and  proceeding  naturally  in  his  researches  on 
thoracic  sensibility  of  the  patient  from  right  to  left,  the  latest  impres- 
sions perceived  by  the  patient  were  on  the  left,  and  that  consequently 


148  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

suggestion  had  considerably  greater  chances  of  being  made  on  the  left- 
hand  side. 

This  argument  hardly  deserves  discussion,  for  it  implies  that  one 
always  studies  sensibility  beginning  on  the  right-hand  side  of  the  body. 
To  us  the  criticisms  which  are  made  concerning  the  methods  of  examina- 
tion of  sensibility  are  much  more  important.  It  is  evident  that  any 
process  of  examination  which  draws  the  attention  of  the  subject  to  his 
sensibility  contains  in  that  very  fact  an  element  of  suggestion.  It  is 
certain  that,  if  one  asks  the  patient,  "Can  you  feel  better  on  the  right 
than  on  the  left?"  or  says,  "Tell  m^  as  soon  as  you  feel  this  less 
distinctly,"  etc.,  one  directly  suggests  his  angesthesia  to  him,  just  as, 
in  other  cases,  when  one  puts  the  question  to  him,  "Where  am  I  touch- 
ing you  ?  '  '  one  suggests  to  him  that  he  must  be  able  to  feel.  There  are, 
however,  many  methods  employed  which,  in  the  majority  of  cases,  even 
when  practised  by  physicians  who  are  not  on  their  guard  in  this  matter, 
contain  no  element  of  suggestion.  They  are  such  as  are  used  when 
testing  for  thermoaneesthesia.  In  the  majority  of  cases  they  lay  a  hot  or  a 
cold  body  on  the  skin  of  the  patient  and  ask  him,  '  '  What  do  you  feel  ?  is 
it  hot  or  cold  ?  '  '  This  is  the  natural  question  which  we  have  heard  asked 
almost  spontaneously  even  by  very  young  students. 

Now,  under  these  conditions,  where  the  patient  is  not  asked  if  he 
feels  anything,  but  where  he  is  asked  to  define  the  nature  of  his  sen- 
sations, if  there  be  a  suggestion  it  will  only  be  a  negative  one.  Never- 
theless, among  nearly  all  hysterical  individuals  afflicted  with  disturbances 
of  the  sensibility,  there  is  a  superposition  of  anaesthesia  and  thermo- 
anaesthesia. 

We  shall  not  dwell  upon  this,  and,  though  we  are  persuaded  that  one 
is  justified  in  doubting  the  rôle  which  suggestion  may  play  in  hysterical 
anaesthesiae,  we  nevertheless  think,  for  all  the  reasons  that  we  have 
given,  that,  in  its  creation  at  least,  hysterical  anaesthesia  is  not  always 
due  to  immediate  or  even  to  remote  suggestion.  We  have,  as  a  matter 
of  fact,  during  the  last  year,  observed  several  cases  of  hysterical  anaes- 
thesia— ^hemianaesthesia,  anaesthesia  of  a  leg,  cuff-like  bands — in  subjects 
who  had  never  had  any  previous  medical  examination.  Finally,  we  con- 
clude this  criticism  of  the  theory  which  holds  that  sensory  disturbances 
of  hysterical  individuals  are  always  the  outcome  of  some  medical  sug- 
gestion by  asking  how  it  is  possible  that  this  suggestion  never  produces 
hyperaesthesia,  but  always  and  only  anaesthesia?  On  the  other  hand,  for 
those  very  cases  where  suggestion  might  have  come  in,  it  will  have  to  be 
explained  why  this  suggestion,  which  is  impossible  for  the  great  majority 
of  people,  can  be  realized  in  certain  subjects  only,  and  precisely  in 
those  who  are  called  hysterics.  The  solution  of  the  problem  of  hysteria 
would  be  set  back  rather  than  advanced. 

Where  does  the  break  take  place  in  the  non-transmission  of  a 
peripheral  stimulus  to  the  cortical  centres? 

This  is  a  third  question  to  which  it  seems  necessary  to  try  to  make 


DISTURBANCES  OF  SENSIBILITY.  149 

some  reply.  As  a  matter  of  fact,  anaesthesia  may  be  produced  by  very 
different  mechanisms.  One  may  theoretically  conceive  of  the  existence 
of  an  angesthesia  due  to  a  lack  of  stimulation  of  the  peripheral  nerves 
even  under  the  influence  of  a  normal  stimulus,  to  lack  of  transmission, 
or  lack  of  reception  of  the  stimulation  produced,  and  finally  to  a  lack 
of  perception.  This  last  form  of  anaesthesia  supposes  simply  the  sup- 
pression of  mental  images  which  lead  to  a  knowledge  of  and  judgment 
concerning  the  peripheral  stimulation.  It  is,  properly  speaking,  psychic 
anaesthesia.  In  the  immense  majority  of  cases  hysterical  anaesthesia  be- 
longs to  this  latter  group,  as  may  be  clearly  seen  in  studying  the 
clinical  characteristics  of  this  anaesthesia.  If,  as  a  matter  of  fact,  con- 
scious sensibility  has  disappeared,  there  persists  a  subconscious  sensibility 
which  expresses  itself  by  the  dilatation  of  the  pupils  following  the 
unfelt  painful  stimulation,  which  shows  itself  also  when  the  subject  is 
distracted,  and  which  at  all  events  allows  instinctive  phenomena  to  per- 
sist, whence  the  rarity  of  unperceived  traumatisms  in  hysterics  as  well 
as  the  persistence  of  cutaneous  reflexes  in  them,  due  to  the  complete 
integrity  of  the  primary  and  secondary  reflex  arcs. 

But  we  have  seen  that  this  immunity  of  hysterics  to  unconscious 
traumatisms  is  not  as  complete  as  we  have  been  led  to  believe.  On  the 
other  hand,  there  are  cases  where  the  cutaneous  reflexes  are  abolished 
on  the  side  of  the  hemianaesthesia  while  they  persist  on  the  sensitive  side, 
which  wholly  eliminates  the  hypothesis  of  the  congenital  absence  of  the 
missing  reflex.  One  of  us  has  been  able  lately  to  establish  in  three 
patients  suffering  from  hemianœsthesia  the  unilateral  suppression  of  the 
plantar  cutaneous  reflex  and  of  the  fascia  lata  reflex.  He  was  able  in 
another  patient  to  establish  in  the  same  way  the  suppression  of  the 
cremasteric  reflex.  Now,  these  facts  are  evidently  difficult  to  interpret 
if  one  persists  in  considering  hysterical  anaesthesia  as  a  purely  psychic 
anaesthesia,  so  much  so  that  one  is  led  to  ask  oneself  if  under  some 
circumstances  the  angesthetic  trouble  does  not  arise  from  another  mechan- 
ism, and  if  the  interruption  in  sensibility  may  not  occur  at  some  lower 
plane. 

In  short,  if  we  sum  up  the  conclusions  which  have  been  developed 
by  this  discussion,  we  must  admit  that  they  are  all  of  a  negative  nature, 
and  that,  to  our  way  of  thinking,  hysterical  anaesthesiae  are  neither  always 
phenomena  of  simulation  nor  always  phenomena  of  suggestion  nor  always 
purely  psychic  anaesthesiae. 

We  now  come  to  our  personal  conception  of  these  phenomena.  In 
our  opinion,  there  exist  three  classes  of  hysterical  anaesthesiae.  In  the 
first  series  of  facts  one  may  place  the  cases  due  to  simulation.  In  the 
second  group  of  cases  we  shall  range  the  patients  in  whom  the  disturb- 
ances of  sensibility  are  directly  due  to  suggestion.  Finally  there  remains 
a  third  class  of  patients  in  whom  the  disturbances  of  sensibility  seem 
to  us  to  be  residual  emotional  phenomena. 

Like  all  the  other  conceptions,  our  way  of  looking  at  this  is  evi- 


150  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

dently  only  an  hypothesis,  but  it  is  an  hypothesis  to  which  the  facts 
seem  to  point  with  peculiar  directness.  We  showed,  first  of  all,  at  the 
beginning  of  this  study,  that  emotion  was  able  to  suppress  sensibility 
completely  by  producing  absolute  side-tracking,  and  that  under  such 
circumstances  it  was  really  a  question  of  total  anaesthesia,  and  not  purely 
psychic  anaesthesia,  such  as  we  had  seen  in  accidents  happening  to  people 
who  were  psychotic  or  in  a  state  of  great  mental  excitement  which  they 
did  not  even  try  to  avoid.  The  subjects  under  such  circumstances  paid 
attention  to  nothing  and  felt  nothing.  When  the  state  has  passed  and 
the  emotional  cause  has  disappeared,  the  sensibility  may  return  ;  but  the 
anaesthesia  may  also  persist,  either  by  auto-suggestion  which  is  preserved 
in  an  individual  who  remarks  that  he  has  felt  none  of  the  various  in- 
juries which  he  has  experienced,  or  it  is  a  question  of  a  simple 
residual  phenomenon  independent  of  all  suggestion.  In  the  one  case 
as  in  the  other,  the  topography  of  the  residual  disturbances — ^the  anaes- 
thesia being  psychic  originally,  but  with  inhibitions  and  multiple  irradia- 
tions and  added  complex  phenomena — will  always  appear  in  accordance 
with  the  usual  mental  representations  of  the  sensibility, — that  is  to  say, 
according  to  regional  representations.  Hence  the  segmentary  anaesthesia, 
and  hence  the  hemiangesthesia. 

This  theory  will  explain  the  numerous  cases  where  one  sees  dis- 
turbances of  sensibility  directly  following  some  emotion,  and  chiefly  an 
* 'emotional  shock,"  of  which  we  have  also  been  able  to  observe  several 
examples,  and  without  which  there  would  have  been  that  cumulative 
period  which  usually  precedes  hysterical  attacks. 

In  other  words,  we  admit  that  the  phenomena  which  emotion  can 
create  are  the  phenomena  which  the  hysterical  individual  is  able  to 
preserve. 

The  emotion,  at  the  same  time  that  it  modifies  the  function,  inhibits 
the  corresponding  mental  representations,  and  what  remains  after  the 
emotion  naturally  bears  some  relation  to  the  antecedent  representations. 
The  latter  are  evidently  subordinated  to  questions  of  education,  reason- 
ing, and  all  sorts  of  acquisitions.  We  do  not  feel  any  pain  or  anaes- 
thesia in  the  territory  of  a  nerve  ;  we  feel  it  in  the  arm,  in  the  wrist,  or 
the  hand;  we  feel  it  on  the  right  or  on  the  left  side;  and  this  is  why 
hysterical  anaesthesiae  are  hemianaesthesiae  or  segmentary  anaesthesiae, 
superimposing  themselves,  so  to  speak,  on  the  antecedent  mental  repre- 
sentations. These  broad  mental  representations,  which  are  in  some 
degree  primary,  command  the  whole  series  of  final  representations.  If 
we  feel  a  pain,  the  psychic  localizing  is  made  in  a  progressive  fashion; 
one  has  a  pain  in  such  a  finger,  or  such  a  joint,  or  at  a  certain  part 
of  the  hand.  The  secondary  manifestations  are  subordinated  to  the 
primary  representation  which  includes  them  all.  And  in  the  emotional 
residue,  in  the  phenomena  of  auto-suggestion,  which,  as  we  shall  see 
further  on,  cannot  be  separated  from  the  emotion,  the  localizations  take 


DISTURBANCES  OF  SENSIBILITY.  151 

place  according  to  the  primary  mental  representations.  It  is  the  whole 
half  of  the  body,  the  whole  limb,  or  a  segment  of  a  limb  from  which 
sensibility  disappeai^. 

The  question  which  remains  to  be  solved  would  be  to  find  out  if 
the  mental  representation  corresponds  to  anatomical  facts;  if  the  mode 
of  psychic  localization  of  impressions  corresponds  to  the  regional  cortical 
distribution  of  sensibility,  just  as  the  hysterical  paralyses  may  cor- 
respond to  a  regional  distribution  of  motor  images.  It  is  very  certain 
that  our  intellectual  acquisitions  ought  to  comply  to  cerebral  anatomical 
conditions,  and  be  superimposed  upon  them.  And  under  these  con- 
ditions there  would  be  nothing  extraordinary  if,  as  regards  territory, 
the  hysteric  hemian£esthesia  should  be  identical  to  the  organic  hemianaes- 
thesia.  Thus  we  may  conceive  that  emotion  may  act  almost  anatomically, 
and  its  effects  become  secondarily  localized. 

This  long  digression  outside  of  the  realm  of  clinical  facts,  and  evi- 
dently purely  hypothetical,  has  nevertheless  appeared  to  us  justifiable. 
Further  along,  in  our  general  study  of  the  psychoneuroses,  the  full 
theoretical  importance  of  this  interpretation  of  facts  will  appear  more 
clearly. 

Outside  of  these  limited  anaBsthesias  one  may  observe,  as  a  result 
of  great  emotions,  a  general  anaesthesia,  extending  over  the  whole 
tegumentary  surface.  During  hysterical  crises  it  is  a  common  occur- 
rence, but  it  may  linger  after  the  attack.  Usually  it  resolves  itself 
into  a  hemianassthesia,  or  a  residual  segmentary  anaesthesia,  which  fact 
also  helps  to  prove  the  truth  of  our  idea. 

Finally,  disturbances  of  sensibility  may  be  less  marked  and  appear 
as  a  simple  hypaesthesia.  As  this  slight  disturbance  is  very  difficult 
to  determine  without  bringing  in  the  element  of  suggestion,  we  would 
be  quite  inchned  to  believe  that  there  is  often  opportunity  for  more  or 
less  conscious  simulation.  The  patient  who  pretends  not  to  be  able  to 
feel  as  distinctly,  but  who  feels  all  the  same,  who  hesitates  about  the 
exact  limitations  of  his  sensations,  is,  by  the  very  nature  of  things, 
directly  susceptible  to  suggestion  by  the  examination,  and  one  should 
at  least  be  very  reserved  in  making  any  statements  concerning  the 
objective  reality  of  such  manifestations.  We  shall  not  dw^ell  upon  the 
clinical  characteristics  of  these  various  anaesthetic  disturbances.  We 
have  pointed  out  the  majority  of  them  in  our  theoretical  discussion. 
Nevertheless  they  are  quite  classic.  The  equal  affection  of  all  kinds 
of  sensibility,  association  with  sensory  disturbances,  involvement  of 
deep  sensibilities,  the  equality  of  the  degree  of  anaesthesia  at  all 
points,  at  the  base  as  well  as  the  extremity  of  the  limbs,  their  ready 
disappearance  under  psychotherapeutic  influences,  are  each  and  all  the 
peculiar  attributes  of  this  kind  of  manifestations. 

(&)  The  Hyperœsthesiœ. — The  hyperaesthesiae — or,  what  is  the  same 
thing,  the  hyperalgesiae — consist  in  the  objective  increase  of  painful 


152  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

sensibility.  When  they  are  very  marked,  tactile  sensibility  becomes  in 
a  certain  way  sensibility  to  pain;  sometimes  a  very  light  touch,  simply 
brushing  over  the  hyperaesthesic  region,  is  enough  to  produce  very 
marked  impressions  of  pain. 

When  arising  in  this  way,  a  hyperaesthesia  localized  in  any  one  area 
of  the  skin  is  an  hysterical  phenomenon.  The  hysterical  zones,  the 
ovary  and  the  breasts,  etc.,  which  have  in  their  day  had  a  certain 
celebrity,  are  in  reality  hyperaesthetic  zones. 

The  mechanism  by  which  these  zones  are  developed  is  variable. 
More  often — not  always,  however — they  are  the  result  of  pure  hetero- 
suggestion.  Sometimes  auto-suggestion  may  come  in,  and  the  cutaneous 
zone  in  which  the  objective  hyperaesthesia  has  been  established  becomes 
either  subjectively  or  actually  painful,  without,  however,  in  the  cases 
in  which  we  have  been  interested,  our  being  able  to  detect  any  real 
nervous  lesion.  We  have  seen  neurasthenics  suffering  from  vertebral 
topalgia, — that  is  to  say,  from  a  purely  subjective  disturbance  of  sensi- 
bility— who,  by  estabhshing  an  hysterical  association,  have  developed  a 
distinctly  exaggerated  sensibility  in  the  theoretically  painful  zone.  As 
for  the  hypergesthetic  localizations,  they  defy  all  description.  Like  all 
suggested  manifestations,  and  quite  the  reverse  from  anaesthetic  troubles, 
they  are  not  fixed,  and  have  no  definite  limits  and  no  permanence  with- 
out a  repetition  of  the  suggestive  actions  which  created  them. 

We  cannot  say  as  much  of  generalized  hyperaesthesia  due  to  emotion, 
of  which  we  have  already  spoken  at  the  beginning  of  this  chapter.  It 
ia  a  frequent  phenomenon  not  only  among  hysterics,  but  also  among 
neurasthenics.  It  is  even  a  common  phenomenon  in  daily  life.  Every 
person  who  is  at  all  neuropathic  has  undoubtedly  had  moments  when, 
to  use  a  popular  expression,  he  has  felt  his  nerves  all  *  *  on  edge,  '  '  where 
the  idea  of  being  touched  seemed  insupportable  to  him,  or  where  the 
slightest  jar  would  throw  him  into  an  emotional  state  with  sometimes 
considerable  exaggeration  of  feeling.  These  conditions,  which  may  be 
found  among  nervous  people — neuropathic  candidates,  but  not  yet  real 
neuropaths — when  they  are  suffering  from  more  or  less  continued  care 
or  worry,  are  not  lasting.  Among  neurasthenics  who  are  suffering 
emotionally  from  some  continuous  cause,  this  condition  is  often  found 
in  a  persistent  form,  and  particularly  in  those  forms  of  neurasthenia 
that  are  predominantly  psychic,  where  the  patient  is  in  a  tense,  excited 
state  rather  than  depressed. 

Here  it  is  evidently  a  case  of  hyperexcitability  or  psychic  irritability 
rather  than  hyperaesthesia  properly  so  called.  This  hyperexcitability 
is  not  limited  to  the  domain  of  general  sensibility,  but  it  can  extend 
still  further,  to  the  domain  of  special  sensibility,  and  even  to  the  general 
ensemble  of  all  vital  manifestations  having  a  psychic  tinge. 

If  only  as  an  aid  to  diagnosis  these  facts  ought  to  be  pointed  out. 
It  is  no  less  true,  however,  that  such  phenomena,  really  belonging  to 


DISTURBANCES  OF  SENSIBILITY.  15a 

the  emotional  state,  are  of  a  nature  which  suggestion  may  develop  but 
cannot  create.  This  is  a  fact  which  is  also  of  importance,  and  to  which 
we  shall  return. 

B.  Subjective  Disturbances  of  Sensibility. — All  the  spontaneous 
sensations  which  are  produced  apart  from  any  stimulus,  and  whose 
general  ensemble  represent  subjective  disturbances  of  sensibility,  are 
excluded  from  the  program  of  our  study.  In  order  to  consider  sub- 
jective disturbance  of  sensibility  as  a  functional  manifestation  we  should 
have  to  admit  that  there  are  some  organic  phenomena  that  are  not 
susceptible  to  explanation.  This  is  the  same  as  saying  that  we  cannot 
consider  any  disturbance  of  the  sensibility  due  to  vascular  or  nervous 
dffl^Hj^ither  direct  or  indirect,  as  a  functional  phenomenon. 

Topalgias,  or  central  psychic  algias,  constitute  practically  the  great 
majority  of  the  subjective  disturbances  of  general  sensibility,  which 
have  been  described  in  the  course  of  the  psychoneuroses. 

These  topalgias  willingly  abandon  the  domain  of  superficial  sensi- 
bility in  order  to  attack  the  region  of  visceral  sensibilities.  A  number 
of  painful  phenomena,  which  graft  themselves  on  the  many  phobic  states 
which  we  have  already  seen,  and  which  we  shall  have  to  analyze,  are  in 
Teality  only  manifestations  of  this  kind.  As  a  matter  of  fact,  these 
are  very  often  regional  manifestations:  pains  in  the  kidneys, — neuras- 
thenic backache, — vertebral  pains,  pains  in  the  nape  of  the  neck,  the 
famous  neurasthenic  helmet.  Sometimes  the  painful  sensations  are  by 
the  patient  more  definitely  localized  in  the  face,  the  forehead,  the  head^ 
the  back  of  the  eyeballs,  or  on  some  point  of  the  vertebral  column, 
such  as  the  coccyx  or  the  region  of  the  neck. 

These  pains  are  of  varying  intensity.  Movement  increases  certain 
of  them,  particularly  the  coccygodynia.  When  they  are  very  sharp  and 
generalized,  they  constitute  akinesia  algera,  characterized  by  absolute 
impossibility  of  the  patient's  making  a  movement  without  feeling  pain- 
ful impressions,  from  which  he  gets  into  the  habit  of  such  a  complete^ 
immobilization  that,  like  a  paralytic,  he  cannot  leave  his  bed.  In  a 
less  marked  degree  this  phenomenon  is  common  among  neurasthenics. 
It  enters  as  an  essential  factor  in  the  so-called  physical  asthenia  with 
which  these  patients  are  afflicted. 

These  painful  impressions  almost  always  belong  to  neurasthenia. 
They  are  essentially  phenomena  of  a  suggestive  nature,  and  later  we 
shall  find  this  fact, — ^namely,  that,  in  anything  that  concerns  subjective 
disturbances  as  well  as  those  of  sensibility,  the  neurasthenic  is  even 
more  suggestible  than  the  hysteric. 

The  majority  of  these  phenomena  come  about  through  the  psychic 
fixation  on  the  part  of  the  patient  of  some  pain  that  had  once  been 
experienced  or  some  emotional  sensation  which  had  once  been  felt. 

The  following  case  is  in  this  respect  most  interesting.  It  is  the 
case  of  a  man,  fifty-six  years  old,  who  for  fifteen  years  had  suffered  front 


154  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

a  localized  pain  at  the  pit  of  his  stomach,  coming  on,  without  any 
relation  whatever  to  the  time  of  eating,  in  the  form  of  attacks  so  in- 
tense that  he  could  neither  sleep  nor  suppress  his  groans.  The  pain 
was  not  clearly  defined  by  the  sufferer,  and  none  of  the  classic  diag- 
noses seemed  to  fit  it.  It  was  not  a  burning  sensation,  neither  was  it 
a  boring  or  tearing  or  stabbing  pain.  In  fact  he  could  not  compare  it 
to  anything.  The  only  definite  idea  that  he  had  about  it  was  of  its 
intensity,  which  he  stated  to  be  very  distressing,  as  was  likewise  the 
calamity  which  it  brought  into  his  life,  which  he  considered  as  hope- 
lessly spoiled  by  it. 

Now,  upon  analysis  this  pain  proved  to  be  nothing  but  the  fixation 
of  an  impression  of  pain. 

As  a  matter  of  fact,  its  onset  coincided  with  a  whole  series  of 
emotional  traumatisms,  caused  by  the  loss  of  his  money  and  losing  of  his 
position,  to  which  anxieties  were  added  family  cares  and  troubles  of 
all  kinds.  During  a  period  of  eighteen  months,  while  the  patient's 
affairs  seemed  to  be  going  better,  these  painful  phenomena  disappeared 
almost  completely,  but  only  to  reappear  without  further  interruption 
when  his  temporal  and  emotional  affairs  were  again  upset.  On  examina- 
tion no  objective  sign  whatever  could  be  found,  but  palpation  of  the 
epigastric  region,  which  was  easy  and  which  did  not  bring  on  muscular 
contractions  of  the  wall,  nevertheless  alw^ays  started  a  subjective  pain 
in  the  patient. 

He  had  naturally  seen  a  great  many  physicians,  who  had  all  ordered 
local  medications,  whose  therapeutic  effects  were  nil,  but  which  had 
had  the  result  of  fixing  more  profoundly  than  ever  in  his  mind  the 
conviction  of  his  incurability. 

By  the  simple  means  of  appropriate  psychotherapy,  this  patient 
was  completely  cured  in  a  fortnight.  This  was  partly  due  to  the 
fact  that  it  was  a  question  of  a  typical  pain,  and  also  to  the  fact  that 
our  patient  was  sufficiently  strong  minded  to  allow  himself  to  be  treated 
by  shaming  him  out  of  it,  which  constitutes  the  only  therapy  for  such 
an  affection. 

Sometimes  there  seems  to  be  no  starting-point  and  the  pain  is 
created  wholly  by  suggestion.  To  appreciate  this  fact  it  is  only  neces- 
sary to  question,  on  the  one  hand,  educated  neurasthenics  who  know 
by  heart  the  classic  symptomatology  of  the  affection  of  which  they 
complain,  and,  on  the  other  hand,  neurasthenics  belonging  to  the 
poorer  and  badly  educated  classes  of  society.  Then  one  can  see  that 
the  helmet  headache,  the  pain  in  the  nape  of  the  neck,  and  pain  in  the 
spine  are  extremely  frequent  among  cultivated  people,  but  much  rarer 
among  the  others. 

On  the  contrary,  pains  with  a  complex  mechanism,  connected  with 
the  psychic  fixation  which  has  come  about  in  connection  with  some 
real  thing,  pains  in  the  kidneys,  that  whole  class  of  visceral  pains,  and 


DISTURBANCES  OF  SENSIBILITY.  155 

simple  headaches  without  the  classic  stamp,  are  met  with  equal  fre- 
quency in  the  two  classes  of  patients  which  we  have  just  designated. 

Another  element  comes  in,  which  is  the  education  of  the  sensibilities 
as  the  result  of  the  attention,  whether  emotional  or  not,  being  foeussed 
on  some  one  point  or  other  of  the  organism.  There  is  no  question  that 
one  may  succeed  by  focussing  the  attention,  even  though  it  be  more  or 
less  complicated  by  phenomena  of  emotion  and  suggestion,  in  educating 
a  visceral  or  peripheral  sensibility  in  just  the  same  way  as  a  blind 
man  or  a  clever  artisan  educates  his  tactile  sensibilities.  But  these 
facts  ought  to  be  put  in  the  group  of  hypersesthesige  rather  than  in 
the  list  of  purely  objective  disturbances  of  sensibility.  They  are  in 
reality  phenomena  of  localized  hyperirritability,  which  may  be  com- 
pared in  their  own  particular  domain  to  the  diffuse  hyperexcitabilities 
which  we  have  already  studied. 

As  a  rule,  a  central  pain  begins  by  being  intermittent.  It  is  a 
pain  that  is  felt  once,  then  forgotten,  then  felt  again  at  the  end  of 
several  days,  and  whose  reproduction  strengthens  the  memory.  Then 
by  progressive  stages  the  suffering  becomes  continuous.  It  is  a  pain 
which  is  dull  and  heavy,  not  sharp  and  poignant.  When  the  patient 
is  left  to  himself  it  is  persistent,  allowing  him  very  little  rest,  but 
nevertheless  it  is  rarely  a  factor  of  insomnia.  As  is  the  case  with  all 
psychic  pains,  as  well  as  all  organic  pains  with  psychic  reinforcement, 
distraction — this  word  being  taken  in  its  etymological  sense — causes  it 
to  diminish  or  disappear.  This,  from  the  point  of  view  of  their  treat- 
ment, is  a  most  important  fact. 

These  localized  pains  are  extremely  interesting  from  every  point  of 
view,  first  on  account  of  their  mechanism,  and  also  on  account  of  the 
various  difficulties  in  diagnosis  which  their  presence  involves.  The 
errors  in  diagnosis  to  which  they  lead  are  made  in  two  ways, — either 
one  mistakes  a  symptom  connected  with  an  organic  disease  for  a 
central  pain,  or,  on  the  other  hand,  one  does  not  recognize  the  functional 
nature  of  the  sensations  perceived  by  the  patient.  We  shall  come  back, 
however,  to  this  question  of  diagnosis. 

In  addition  to  central  pains,  there  are  other  subjective  disturbances 
of  sensibility  which  may  be  observed  in  the  course  of  the  psycho- 
neuroses.  These  are  abnormal  sensations,  but  neither  severe  nor  pain- 
ful, which  belong  to  the  group  of  what  in  France  are  termed  the 
dysaesthesiae.  Restlessness  in  the  limbs,  vague  feelings  of  heat  or  cold, 
without  any  associated  vasomotor  disturbances,  prickings,  creeping, 
tickling  sensations,  etc.,  are  all  distinct  impressions  which  may  be  found 
in  patients  exclusive  of  any  organic  phenomena,  occurring  either 
accidentally  or  more  or  less  permanently.  They  may  coexist  with 
phenomena  of  hypaesthesia  or  anaesthesia,  and  also  be  found  as  isolated 
phenomena. 

They  are  observed  in  hysterical  individuals  in  the  periods  imme- 
diately following  attacks,  but  they  may  just  as  well  be  objective  mani- 


156  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

festations  in  the  domain  of  sensibility  due  to  slight  paralytic  disturb- 
ances. One  meets  with  them  also  in  neurasthenics,  but  more  often  they 
are  merely  a  suggestive  association  in  connection  with  some  phobic 
manifestation,  which  presents  itself  in  the  region  whose  sensibility  is 
disturbed. 

We  are  now,  as  far  as  we  are  able,  done  with  the  disturbances  of 
general  sensibility.  We  are  far  from  having  enumerated  them  all. 
We  have  in  particular  neglected  what  are  called  pargesthetic  manifesta- 
tions,— that  is  to  say,  disturbances  of  objective  sensibility  which  are 
neither  hyperaesthesiae  nor  anaasthesiag.  These  disturbances  (polyaesthesia, 
fusion  or  summation  of  sensation,  exhaustion  of  sensation,  impossibility 
of  localization,  etc.)  are  but  very  rarely  met  with  in  the  course  of 
the  psychoneuroses,  and  only  in  hysteria.  If  we  repeat,  on  the  other 
hand,  that,  in  the  domain  of  objective  sensibility  in  hysterics  and  in 
the  domain  of  algias  and  suggestive  sensibility  in  neurasthenics,  every 
trouble  must  be  studied  individually,  it  will  make  it  sufficiently  clear 
why  and  how  and  in  what  measure  our  study  is  incomplete.  Volumes 
might  be  written  and  have  been  written  on  this  subject.  We  must  be 
satisfied  for  the  time  being  with  having  related  the  commonest  of  these 
disturbances  and  having  shown  how  they  may  become  established 
under  the  triple  influence  of  emotion,  suggestion,  and  education,  and 
by  those  phenomena  which  are  directly  connected  with  them,  such  as 
memory,  attention,  etc. 


CHAPTER  IX. 

FUNCTIONAL  MANIFESTATIONS  OF  THE  SENSE  ORGANS. 

In  this  chapter,  as  in  the  majority  of  the  succeeding  chapters,  we 
have  two  kinds  of  troubles  to  describe.  There  are,  on  the  one  hand,  a 
whole  series  of  phobic  manifestations  which  may  act  upon  the  sense 
organs  as  on  any  other  part  of  the  body,  while,  on  the  other  hand,  there 
are  functional  fixations,  properly  so  called,  translating  themselves  into 
phenomena  which,  although  they  are  subjective  in  origin,  have  none  the 
less  an  objective  appearance.  So  far  as  these  latter  manifestations  are 
concerned,  it  is  often  very  difficult  to  differentiate  them  from  purely 
psychic  fixations.  The  sense  organs  are,  in  fact,  only  anatomical  pro- 
jections of  the  brain,  projections  by  which  the  latter  comes  in  direct 
contact  with  the  external  world.  The  functions  of  the  sense  organs 
being  essentially  functions  of  knowledge,  and  knowledge  being  a  psycho- 
logical fact,  it  happens  that  many  of  the  troubles  which  are  experienced 
are  in  reality  psychic  disturbances  which  we  must  study  elsewhere. 

One  is,  nevertheless,  in  the  right  in  describing  functional  mani- 
festations of  the  sense  organs  when  it  is  a  question  of  the  difficulty  being 
localized  in  a  single  one.  It  is  of  course  understood  that  some  psychic 
disturbance  is  the  cause  in  such  cases,  as  in  all  functional  manifestations, 
but  the  specialization  of  these  disturbances  allows  them  to  be  considered 
as  having  a  certain  autonomy. 

We  shall  take  up  successively  the  functional  disturbances  of  sight, 

hearing,  smell,  and  taste.  • 

^T^he  îunctional  disturbances  of  vision  which  have  been  spoken  of 
in  hysteria  are  extremely  numerous.  More  often  they  are  unilateral,  or 
at  least  in  most  cases  predominant  on  one  side.  They  are  usually, 
therefore,  associated  with  hemianaesthesia,  and  form  a  constitutional 
part  of  what  is  called  sensitive-sensorial  hemianaesthesia. 

Of  all  the  functional  disturbances  of  vision  narrowing  of  the 
visual  field  is  assuredly  the  most  classic.  Bilateral,  with  considerable 
predominance  on  the  anaesthetic  side,  it  is  chiefly  characterized  by  this 
fact,  that  it  becomes  continuously  more  marked  during  the  course  of 
the  perimetric  examination,  so  much  so  that  during  a  prolonged  ex- 
amination the  successive  fields  of  vision  grow  progressively  narrower 
until  under  certain  circumstances  the  visual  field  may  become  a  mere 
point. 

The  hysteric  is  quite  unconscious  of  the  diminution  of  his  field  of 
vision.  It  in  no  wise  hinders  him  in  any  of  his  daily  duties  which 
demand  good  eyesight.  And  he  never  in  any  way  loses  his  sense  of 
orientation. 

The  perception  of  colors  may  be  modified  in  the  hysteric.     In  his 

157 


158  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

ease  the  narrowing  of  the  visual  field  for  colors  is  just  the  opposite  of 
what  one  observes  in  lesions  of  the  optic  nerve.  Instead  of  the  fields 
for  green  and  red  being  the  first  to  disappear,  leaving  the  fields  for 
yellow  and  blue  intact  for  a  longer  time,  in  the  hysteric  it  is  red  which 
persists  longest  in  the  vision.  In  hysterical  achromatopsia  red  may  be 
the  only  color  that  remains. 

Other  ocular  phenomena  observed  among  hysterics  are  sufficiently 
defined  by  the  words  dyschromatopsia,  total  achromatopsia,  micropsia, 
megalopsia,  monocular  polyopia,  kopiopia,  and  painful  accommodation. 
These  phenomena  naturally  are  only  specific  when  one  has  seen  that 
there  is  absolute  integrity  of  the  fundus  and  ocular  structures  and  that 
there  are  no  coexistent  errors  of  refraction. 

Pupillary  symptoms,  such  as  myosis,  bilateral  or  unilateral  mydriasis, 
pupillary  inequality,  slow  pupils,  modification  of  the  condition  of  the 
pupils  during  the  course  of  an  attack,  etc.,  have  been  described  in 
hysteria. 

Other  symptoms  have  also  been  pointed  out  which  involve  the  ex- 
trinsic eye  muscles  and  those  of  the  eyelids,  such  as  blepharospasm 
in  clonic,  tonic,  or  pseudoparalytic  form,  blepharoptosis,  ophthalmo- 
plegia, with  conservation  of  all  the  intrinsic  movements,  strabismus  from 
muscular  spasms,  loss  of  muscular  sense  of  the  eye  muscles,  etc.  Finally 
a  certain  number  of  cases  of  unilateral  amblyopia  or  of  hysterical 
bilateral  amaurosis  have  been  established.  We  shall  attempt  in  a  little 
while  to  interpret  these  various  troubles. 

What  is  more  interesting,  to  our  way  of  thinking,  is  a  whole  series 
of  manifestations  of  a  phobic  nature  which  may  be  met  with  in  neuras- 
thenics. The  commonest  of  all  consists  in  rapid  fatigue  of  vision.  For 
one  reason  or  another,  these  patients  afflict  themselves  by  bringing 
auto-suggestion  to  bear  upon  their  sight.  Sometimes  it  is  because  under 
the  influence  of  an  ophthalmic  migraine  they  have  had  scintillating 
scotomata,  or  else  under  some  influence  of  a  similar  nature  they  have 
suffered  from  photophobia.  Sometimes  it  is  a  medical  consultation 
which  has  directed  the  patient's  ideas.  One  finds  him  then  providing 
himself  with  glasses  of  different  colors,  which  he  changes  according  to 
the  atmospheric  condition.  The  rapid  consequence  of  this  mental  state 
is  that  such  patients  imagine  themselves  to  be  continually  with  a 
veil  before  their  eyes,  and  think  that  they  are  unable  to  read  anything 
that  is  a  little  difficult,  or  to  continue  for  any  length  of  time  without 
experiencing  intense  ocular  fatigue.  There  are  some  who  every  two  or 
three  minutes  close  their  eyelids  to  rest  a  theoretically  fatigued  vision, 
there  are  even  some  who  abandon  part  of  their  occupations,  and  there 
are  still  others  who  go  so  far  as  to  shut  themselves  up  in  a  semi-darkened 
room. 

What  is  the  nature  of  these  troubles  ?  Is  it  true,  as  has  been  said, 
that  it  is  a  real  asthenia  of  vision  which  attacks  these  patients,  cor- 
responding to  a  general  asthenia,  and  considered  by  many  authors  as 


MANIFESTATIONS  OF  SENSE  ORGANS.  159 

organic?  According  to  our  way  of  thinking,  the  mechanism  of  this 
visual  fatiguability  is  in  fact  of  the  same  order  as  that  of  amyasthenia, 
but,  like  the  latter,  has  nothing  to  do  with  organic  phenomena.  That 
the  fatigue  felt  by  these  patients  is  real  is  very  doubtful,  but  from 
what  does  it  come?  It  appears  to  us  that  it  is  generally  due  to  dis- 
harmonie phenomena  which  come  into  play.  The  patients  grow  tired 
quickly  because  they  hold  themselves  too  tensely,  because  their  vision, 
instead  of  acting  in  an  almost  unconscious  manner,  is  voluntarily  made 
to  act  and  is  strained  and  over  attentive.  We  are  only  speaking  now, 
it  must  be  understood,  of  the  function  itself,  for  we  do  not  have  to 
take  up  the  modifications  in  relation  to  the  trouble  of  perception,  these 
latter  being  in  fact  pure  psychic  manifestations.  The  patients  fatigue 
themselves  just  as  any  healthy  subject  would  fatigue  himself  if  he 
fixed  his  gaze  in  a  very  determined  fashion  upon  a  given  point.  Other 
phobic  manifestations  which  are  due  to  the  prolonged  preservation  of 
a  passing  impression  may  also  exist.  One  sees  patients  of  this  kind 
who  will  complain  for  weeks  of  a  foreign  body  which  has  long  since 
been  removed  from  the  eye,  and  who,  by  reason  of  making  movements 
of  their  eyelids,  pressing  the  eye  with  their  handkerchiefs,  and  bathing 
it  with  all  sorts  of  liquids,  end  up  by  having  a  true  conjunctival  irrita- 
tion, accompanied  by  a  more  or  less  continual  lachrymation. 

It  is  by  this  mechanism  that  we  see  a  certain  number  of  neuras- 
thenics creating  for  themselves  what  they  call  ^*a  peculiar  sensitiveness'' 
of  their  eyes,  and  reacting  by  objective  manifestations  to  impressions 
of  cold,  or  to  irritations  caused  by  too  strong  a  light,  etc.  As  a 
matter  of  fact,  these  are  phenomena  of  auto-suggestion  and  of  uncon- 
scious simulation. 

Concerning  the  true  nature  of  the  ocular  troubles  in  hysterics  of 
which  we  have  just  spoken,  it  seems  to  us  that  a  certain  number  of 
distinctions  ought  to  be  made. 

Of  all  the  ocular  or  periocular  phenomena  which  hysterics  may 
present,  and  which  have  been  subjectively  verified  by  a  number  of 
good  observers,  the  most  classic — ^namely,  the  narrowing  of  the  visual 
field — is  perhaps  still  the  one  which  carries  with  it  the  least  conviction. 
It  is  quite  possible  that  this  supposed  stigma  of  hysteria  might  have 
been  in  many  cases  directly  suggested  by  the  medical  examination. 
The  narrowing,  as  a  matter  of  fact,  is  exaggerated  with  the  observers, 
and  varies  in  the  course  of  the  same  observation.  The  fact  that  the^e 
patients  have  no  difficulty  in  anything  that  has  to  do  with  directing 
their  walk,  their  orientation,  the  nature  of  obstacles  to  be  stepped  over 
or  avoided,  etc.,  offers  still  further  arguments  in  favor  of  the  purely 
suggestive — and  apparently  hetero-suggestive — nature  of  this  phenom- 
enon. It  is  very  evident  that  in  a  perimeter  examination  the  subject 
whose  attention  has  been  fixed  upon  a  given  point  will  have  a  tendency, 
to  a  greater  or  less  degree,  to  see  nothing  but  this  isolated  point.  This 
is,  moreover,  very  much  in  accordance  with  the  mental  condition  of 


160  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

hysterics,  in  whom  the  whole  field  of  consciousness  may,  as  has  been 
said,  be  concentrated  on  a  single  perception.  Although  persisting  in 
the  instinctive  or  automatic  mentality,  none  of  the  other  sensations 
raise  themselves  up  to  the  higher  plane  of  perception.  What  under 
these  conditions  would  be  narrowed  in  the  hysteric  is  not  his  visual 
field,  properly  speaking  :  it  is  his  field  of  visual  consciousness.  We  then 
have  to  do  with  an  essentially  subjective  phenomenon,  wholly  different 
from  other  neuropathic  ocular  manifestations. 

Pupillary  disturbances,  such  as  myosis  or  mydriasis,  are  generally 
attributed  to  a  spasmodic  action  affecting  the  constrictors  or  dilators  of 
the  pupil.  How  shall  we  understand  the  mechanism  of  this  spasm? 
The  interpretation  which  may  seem  the  more  plausible,  although  it  is 
none  the  less  wholly  hypothetical,  consists  in  supposing  that  it  is  a 
question  of  the  fixation  of  the  pupil  in  a  state  of  accommodation 
determined  for  sight  at  a  distance  (mydriasis),  or  for  sight  near  to 
(myosis).  This,  therefore,  would  be  at  bottom  nothing  more  than  an 
exaggeration  in  intensity  and  duration  of  a  normal  phenomenon.  When 
a  subject  is  in  a  condition  of  concentrated  attention, — or,  on  the  con- 
trary, when  he  is  lost  in  revery,  and  his  eyes  ''look  into  space,  seeing 
nothing,'' — there  is  produced  a  contraction  or  dilatation  of  the  pupil. 
It  is,  therefore,  a  question  of  function  indirectly  submitted  to  the 
will,  and  one  can  very  well  understand  that  the  hysteric  whose  eyes 
are  ''lost  in  space,"  or  have  a  fixed  stare,  may  have  a  permanent 
dilatation  or  constriction  of  his  pupil. 

So  far  as  bilateral  amaurosis  is  concerned,  it  is  thought  that  there 
exists  a  true  blindness  of  psychic  origin,  where  the  patients  can  no 
longer  see,  because  they  really  do  not  look.  In  such  cases  there  is  only 
an  exaggeration  of  the  narrowing  of  the  visual  field,  and  a  suppression 
not  of  sensation,  but  rather  of  visual  perception.  Here  again  the 
action  of  suggestion  preponderates,  but  it  must  be  understood  that 
manifestations  of  this  kind  may  be  self-created  by  the  inhibition,  as  it 
were,  of  all  visual  mental  representations.  It  is  not  unusual  to  see 
people  who  under  the  influence  of  strong  emotions  almost  completely 
lose  all  visual  idea,  so  that  they  no  longer  distinguish  obstacles  or  recog- 
nize a  person  right  before  them.  It  is  very  evident  that  in  cases  of 
this  kind  automatic  elementary  visual  perception  persists  even  when 
conscious  perception  has  disappeared. 

Paralyses  and  contractures  of  the  extrinsic  ocular  muscles — which 
are,  however,  very  rare — seem  to  us  to  be  pathologically  identical  with 
those  of  paralysis  or  contractures  of  other  muscles  of  the  body:  con- 
tractures of  defence,  so  to  speak,  by  the  voluntary  turning  of  the  eye 
in  a  given  direction;  paralysis  or  contracture  by  paralyses  of  the 
opposing  muscles,  by  loss  of  ideomotor  representations  of  direction  of 
sight,  in  a  given  sense. 

As  far  as  the  phenomena  of  achromatopsia  and  of  dyschromatopsia 


MANIFESTATIONS  OF  SENSE  ORGANS.  161 

are  concerned,  they  seem  to  us  to  share  the  same  direct  suggestive  action 
as  narrowing  of  the  visual  fields. 

Neuropaths  may  present  a  certain  number  of  fixations  of  the  auditory 
apparatus. 

In  the  same  manner  that  we  have  just  seen,  that  a  psychic  blindness 
may  occur  in  certain  hysterics,  so  in  this  same  class  of  patients  cases 
of  psychic  deafness  may  be  found.  This,  to  tell  the  truth,  is  a  very 
rare  manifestation,  and  in  the  cases  in  w^hich  it  has  been  observed  one 
must  make  a  good  many  reservations.  As  a  matter  of  fact,  it  has  not 
been  proved  that  simulation  cannot  come  into  play  in  these  cases. 
Theoretically,  however,  one  can  conceive  of  the  existence  of  psychic 
deafness  with  a  pathogeny  quite  similar  to  that  of  the  blindness  of 
hysterics. 

Other  troubles  which  are  much  more  apt  to  be  met  with  in  hysterics 
seem  to  us  to  be  far  more  important.  Hysterics  often  complain  of 
their  auditory  functions.  They  say  they  hear  poorly,  cannot  follow 
the  conversation  when  several  people  are  talking  together,  and  are 
obliged  to  have  the  same  words  or  phrases  repeated  several  times.  These 
are,  in  reality,  phobic  manifestations.  They  happen  on  the  occasion  of 
some  incident  connected  with  hearing,  and  have  two  different  mechan- 
isms. It  is  always  a  question  of  what  one  might  caU  deafness  of  atten- 
tion. Sometimes,  however,  it  is  due  to  lack  of  attention,  and  sometimes 
to  excess.  Here,  for  example,  is  a  patient  more  or  less  preoccupied, 
concentrated  upon  his  own  condition,  and  experiencing  all  kinds  of 
feelings  of  depression.  It  is  quite  evident  that  under  these  conditions 
he  would  be  likely  to  hear  only  in  part  or  inaccurately  whatever  might 
be  said  to  him.  This  is  deafness  due  to  distraction.  It  may  happen 
that  the  patient  has  noticed  this,  and  that  he  is  disturbed  by  having 
heard  badly,  and,  if  it  so  happens  that  medical  intervention  has  further 
fiLxed  his  mind  on  the  subject,  he  may  have  auditory  disturbances  due 
to  excess  of  attention.  The  excess  of  attention  paid  to  the  hearing  of 
one  word  hinders  the  hearing  of  the  following  word.  Here  again  is  a 
phenomenon  of  the  disharmonie  order  attacking  the  normal  automatism 
of  the  function  of  hearing. 

Another  manifestation  consists  in  irritability  to  noises.  Neuras- 
thenics will  very  frequently  tell  you  that  they  cannot  bear  the  slightest 
noise,  and  that  certain  noises  in  particular  are  extremely  irritating 
to  them.  Is  this  one  of  those  signs  of  irritable  weakness  in  neurasthenics 
which,  according  to  a  number  of  authors,  forms  the  essential  character- 
istic symptoms  of  this  affection,  or  is  it  a  special  susceptibility  of 
audition?     This  point  must  be  made  clear. 

In  all  kinds  of  emotional  states,  and  states  of  concentration,  in  which 
the  subject  absorbed  in  himself  loses,  so  to  speak,  contact  with  the 
external  world,  it  is  very  certain  that  all  sensory  stimuli  are  felt  more 
vividly.  It  is  the  same  phenomenon  as  that  which  makes  a  normal 
individual  start  on  hearing  some  noise  which  he  was  not  expecting. 
11 


162  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

One  might  say  that  the  sensation  is  reinforced  by  the  surprise  which 
it  occasions.  In  the  neurasthenic  the  same  thing  is  true,  and  the  best 
proof  of  it  is  that  he  is  insensible  to  sounds  which  he  himself  volun- 
tarily makes.  His  irritability  to  noise  is,  as  a  matter  of  fact,  only  an 
outward  expression  of  his  concentration  on  himself. 

On  the  other  hand,  this  same  irritability  to  noise  is  found  in  all 
subjects  who  are  psychically  depressed,  in  whom  under  these  circum- 
stances there  exists  a  very  real  condition  of  irritable  weakness.  The 
condition  of  the  nervous  system  in  these  cases  is  only  an  expression  of 
the  general  condition.  It  may  happen,  in  a  certain  number  of  neuras- 
thenics who  are  emaciated  and  more  or  less  cachectic,  that  factors  of 
this  nature  intervene  in  causing  the  phenomenon. 

Finally, — ^we  might  almost  say,  above  all, — ^phobic  phenomena  may 
play  their  rôle  in  the  genesis  of  this  very  special  irritability.  The 
patient  who  is  exasperated  by  noise — ^whether  he  regards  it  as  an 
external  sign  of  the  slight  attention  which  his  family  pays  to  his  con- 
dition, or  whether  he  has  interpreted  his  lack  of  sleep  as  due  to  the 
disturbances  or  lack  of  quiet  around  him — adds  a  psychic  factor  to  his 
auditory  perceptions.  The  irritability  in  this  particular  case  is  purely 
mental,  and  has  nothing  to  do  with  any  auditory  trouble.  Other 
mechanisms  intervene  by  association  of  ideas,  with  the  result  that  when 
a  noise  has  once  been  the  cause  of  a  disagreeable  sensation  the  same 
noise  always  reproduces  the  same  impression. 

Other  patients  complain  of  buzzings  and  thumping  in  the  ear. 
There  are  people  who  attribute  persistent  insomnia  to  manifestations 
of  this  kind.  Sometimes  this  is  due  to  memories  which  are  continually 
recalled.  There  are  patients  who  by  reason  of  the  presence  of  a  little 
wax  in  the  ear,  or  for  some  other  reason,  have  accidentally  had  buzzings 
in  the  ear.  When  the  cause  itself  has  disappeared  they  continue  to 
experience  the  same  phenomenon.  In  reality  it  is  nothing  but  a  pure 
psychic  recall.  Sometimes  medical  treatment  has  intervened, — catheteri- 
zation of  the  eustachian  tube,  massage  of  the  tympanum,  etc.,  have  been 
practised  when  the  trouble  was  purely  subjective, — with  the  prompt 
result  of  turning  the  patient's  mind  and  fixing  it  on  his  ear,  thus 
transforming  sensations  which  should  have  been  merely  passing  into 
a  veritable  obsession,  which  the  patient  externalizes  in  various  degrees. 
Under  other  circumstances,  these  would  be  patients  who,  as  a  result 
of  some  emotional  experience,  might  have  felt  sensations  of  dizziness, 
and  who  were  told  that  they  had  '* auricular  vertigo."  Still  other  cir- 
cumstances may  be  the  cause  of  establishing  the  phenomenon. 

As  for  the  drumming  and  whistling  and  buzzing  sounds  which 
patients  notice  in  their  ears,  they  are  facts  which  are  very  easy  to 
explain.  They  are  due  simply  to  the  fact  that  the  subjects  whose 
attention  has  been  brought  to  bear  upon  them  have  succeeded  in  being 
able  to  hear  their  arterial  beating,  a  thing  which  any  one  may  learn 
to  do  with  a  little  attention.    But,  although  the  phenomenon  is  trifling^ 


IVIANIFESTATIONS  OF  SENSE  ORGANS.  163 

the  consequences  which  the  patients  draw  from  it  are  not  so.  Some- 
times very  strong  obsessions  arise,  so  much  so  that  the  subjects  who 
are  afflicted  by  them  spend  their  nights  in  watching  for  and  experienc- 
ing these  sensations,  which  are  perfectly  natural,  but  are  magnified  out 
of  all  proportion. 

Finally,  there  are  no  effective  localizations  in  the  auditory  organs  in 
neurasthenics  which  may  not  become  the  starting-point  of  an  intensive 
diffusion  of  symptoms  with  phobic  manifestations  of  all  kinds  if  the 
physician  be  not  careful  to  understand  his  patient's  moral  condition. 

The  olfactory  apparatus  is  not  spared  in  the  course  of  the  psycho- 
neuroses.  Under  the  name  of  anosmia  we  shall  consider  the  loss  of 
olfactory  sensations  as  found  in  a  certain  number  of  hysterics,  either 
isolated  or  associated  with  psychosensory  hemianassthesia. 

We  shall  come  back  very  soon  to  sensory  hemianaBsthesia  associated 
with  psychic  hemianœsthesia.  As  far  as  bilateral  anosmia  is  concerned, 
it  seems  to  us  to  develop  from  a  mechanism  which  is  comparable  to  that 
of  psychic  blindness  or  deafness.  In  this  instance  also  there  is  no 
suppression  of  sensation,  but  suppression  of  perception,  and  the  very 
patients  who  maintain  that  they  do  not  smell  the  odor  of  a  strong  perfume 
will  make  good  their  escape,  for  example,  from  an  environment  filled 
with  odors  of  gas.  The  automatism  persists  in  such  eases  even  when 
the  conscious  and  voluntary  idea  has  disappeared. 

There  are  also  secretory  and  vasomotor  modifications  of  the  olfactory 
mucous  membrane  which  may  be  of  a  purely  neuropathic  nature.  It 
has  been  thought  that  epistaxis  in  certain  hysterics  might  be  considered 
as  a  supplementary  flux  occurring  instead  of  and  taking  the  place  of 
absent  menses.  This  is,  however,  far  from  being  the  fact.  In  the  first 
place,  amenorrhoea  in  the  hysteric  is  much  less  frequent  than  one  is 
led  to  believe,  and  under  these  same  conditions  epistaxis  is  not  frequent. 
It  is  really  only  a  question  of  coincidence  in  such  cases,  and  the  relation 
of  causality  between  these  phenomena  is  probably  due  to  the  mental 
vagaries  current  at  some  period  rather  than  to  any  real  pathological 
association. 

We  cannot  say  as  much  for  nasal  hydrorrhœa.  This  is  a  phenomenon 
which  may  be  observed  not  only  in  hysterics,  but  also,  much  more 
frequently,  under  certain  special  circumstances,  in  the  neurasthenic. 
The  nasal  secretion  is,  as  a  matter  of  fact,  liable  to  be  directly  influenced 
by  the  psychism.  And  the  latter,  on  the  other  hand,  is  capable  of 
directly  creating  sensations  identical  to  those  which  result  from  a  real 
nasal  secretion.  It  is  so  true,  that,  in  an  individual  with  the  least 
tendency  toward  any  neuropathic  traits,  it  is  only  necessary  for  him  to 
notice  that  he  has  forgotten  his  handkerchief  in  order  to  have  this 
simple  idea  cause  him  the  most  intense  and  legitimate  desire  to  use  one. 
It  is  the  same  mechanism  of  this  supposed  susceptibility  of  the  mucous 
membranes  which  one  finds  in  a  certain  number  of  neurasthenics.  There 
are  some  who  pretend  that  they  are  so  extremely  delicate  that  they 


164  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

cannot  stand  any  change  of  air  or  environment  without  catching  cold. 
As  a  matter  of  fact,  it  is  simply  a  question  of  psychic  fixation  on  the 
mucous  membrane.  It  is  possible  for  a  more  or  less  abundant  nasal 
secretion  to  be  produced  by  psychic  mechanism;  but  even  if  this 
phenomenon  does  not  take  place,  the  patient  wants  to  use  his  handker- 
chief, and  does  so.  He  spends  several  hours  in  this  way,  until  his  eyes 
have  become  swollen  and  filled  with  tears,  and  his  nose  slightly  congested, 
when  he  has  the  great  satisfaction  of  displaying  to  himself  as  well  as 
to  others  the  effect  of  a  violent  cold.  As  a  rule,  it  does  not  last.  These 
are  the  colds  which  linger  for  two  or  three  hours,  which  caught  in  the 
morning  have  passed  away  by  lunch  time.  Unfortunately,  however, 
it  does  not  always  happen  in  this  way,  and  often  the  idea  may  become 
fixed  and  diffused  into  a  veritable  obsession  which  spoils  the  patient's 
whole  life.  We  do  not  wish  to  slander  the  specialist  on  this  point;  it 
has  happened  many  times,  however,  that  we  have  seen  such  a  psychic 
fixation  which  has  had  a  most  disastrous  effect  upon  the  patient's  fife 
and  which  was  almost  wholly  due  to  medical  suggestion. 

People  who  have  made  themselves  ill  along  the  lines  analogous  with 
that  which  we  have  just  described  and  find  themselves  excessively  prone 
to  coryzas  go  >to  consult  a  specialist.  It  is  very  rare  that  they  are  not 
upheld  in  the  necessity  for  this  consultation  by  receiving  some  prescrip- 
tion,— nasal  douches,  slight  cauterizations,  powders,  or  ointment  to  snuff 
up.  More  often  the  specialist,  who  has  perceived  how  mild  the  trouble 
is  or  that  it  really  does  not  exist,  has  not,  however,  given  due  con- 
sideration to  the  mental  condition  of  the  subject  who  is  afflicted.  He 
may  have  said  to  the  patient,  *'  It  is  a  very  trifling  affair.  Do  so 
and  so."  This  would  seem  to  be  a  very  unimportant  statement,  but 
often  it  is  too  much.  It  is  enough  in  any  case  to  make  the  patient 
believe  that  he  was  justified  in  being  uneasy  and  to  make  him  hence- 
forth give  himself  up  to  a  series  of  physical  and  mental  gymnastics  in 
the  matter  of  autoobservation.  An  obsession  quickly  follows,  which  is 
serious  not  so  far  as  its  object  is  concerned,  but  in  itself,  and  by  the 
disturbance  which  it  brings  to  normal  life  by  throwing  a  whole  symp- 
tomatology which  had  hitherto  been  subjective,  into  objective  form. 
This  obsession  will  progress  more  rapidly  and  become  more  tenacious 
if  the  patient  is  put  through  a  course  of  surgical  treatment,  such  as 
removal  of  the  turbinated  bones,  cauterizations,  galvanocauterizations, 
etc.,  legitimate  perhaps  in  themselves,  but  which  the  moral  condition 
of  the  patient  should  interdict,  just  as  in  serious  cardiac  conditions  the 
use  of  chloroform  would  be  interdicted. 

We  have  seen  subjects — and  they  were  not  hypochondriacs — who 
had  led  a  most  miserable  life  for  months,  even  years,  because  it  had 
been  shown  and  proved  to  them  that  they  were  not  able  to  breathe  as 
well  through  one  nostril  as  through  the  other.  In  fact,  we  might  repeat 
for  these  patients  all  that  we  have  said  for  our  false  gastropaths. 

Finally,  there  is  one  last  fact  bearing  upon  smell  which  concerns 


MANIFESTATIONS  OF  SENSE  ORGANS.  165 

the  manner  in  which  odors  are  borne  by  neuropaths.  It  is  understood 
that  hysterical  individuals  in  general,  and  in  greater  degree  those 
afflicted  with  anosmia  among  them,  are  wholly  indifferent  to  odors. 
The  same  is  not  true  for  any  great  number  of  neurasthenics.  These 
latter  may  experience  in  the  presence  of  odors  in  general,  and  of 
certain  odors  in  particular,  a  very  special  irritability,  going  so  far  aa 
to  form  a  real  phobic  manifestation.  It  must  be  understood  that  we 
are  not  speaking  now  of  obsessions  in  regard  to  odors,  a  mental  mani- 
festation which  may  be  met  with  in  certain  neurasthenics  who  are 
perfectly  aware  of  the  obsessive  nature  of  the  phenomenon  experienced 
by  them.  Here  the  question  is  not  at  all  the  same;  the  neurasthenics 
make  a  phobia  of  odors  just  as  they  do  a  phobia  of  noise,  because  the 
odor  disturbs  them  in  their  meditations,  and  because,  having  once  been 
annoyed  in  this  way,  they  are  more  or  less  continuously  calling  up  the 
sensation  which  they  once  experienced  by  the  fear  of  its  repetition. 

It  is  possible  for  matters  to  go  still  a  little  further  and  for  certain 
patients  to  be  haunted  by  odors.  This  is  a  case  of  a  more  marked 
mental  phenomenon,  but  one  which  never  has  the  intensity,  the  tenacity, 
or  the  autonomy  of  the  manifestations  of  the  same  kind  which  are  met 
with  in  the  well-defined  psychoses. 

Tdste  may  also  present  a  certain  number  of  derangements  in  the 
course  of  the  psychoneuroses.  Unilateral  diminution  of  taste  is  found 
along  with  psychosensory  hemiangesthesia,  associated  with  the  dis- 
turbances of  all  the  other  modes  of  sensibility.  The  phenomenon  may 
be  so  marked  that  patients  are  incapable  of  differentiating  sugar  from 
salt  on  one  side  of  the  tongue,  which  difference  they  can  determine 
immediately  if  the  object  is  placed  on  the  other  side.  We  shall  discuss 
the  interpretation  of  this  phenomenon  a  little  further  on. 

Total  ageusia,  as  an  isolated  symptom,  has  been  observed  in  certain 
patients  with  hysteria.  As  an  independent  fixation  it  is  a  rare  phenom- 
enon. What  is  very  commonly  found  in  many  patients  is  disturbance  of 
taste  of  all  kinds,  associated  with  digestive  troubles.  Take,  for  example, 
a  mental  anorexic  or  a  neurasthenic  suffering  from  a  false  gastropathy; 
it  is  very  common  to  hear  these  patients  complain  of  the  lack  of  taste 
in  all  their  food.  Inversely,  one  can  find  subjects  in  whom  the  gus- 
tatory sensations  are  exaggerated.  They  find  their  dishes  too  well 
done  or  underdone,  with  too  much  or  too  little  seasoning,  etc.  Finally, 
it  is  customary  to  find  olfactory  irritability  associated  with  gustatory 
irritability. 

In  reality  there  is  no  perversion  of  taste.  If  the  gustatory  sensi- 
bility is  tested  it  is  found  to  be  normal.  There  are  only  purely  sub- 
jective symptoms  attending  the  anorexia  of  these  patients,  and  this  is 
so  true  that  from  one  day  to  another,  depending  upon  the  mental 
orientation  of  these  patients,  their  excessive  sensibility  in  the  matter 
of  taste  may  suddenly  pass  over  into  a  characteristic  lack  of  taste.  In 
one  hotel  they  may  find  the  cooking  insipid,  and  in  another  they  will 


166  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

find  the  seasoning  quite  too  high.  In  this  case  there  is  nothing  but 
an  exterioration  or  projection  upon  the  given  organs  of  a  psychic 
digestive  systematization. 

Under  other  circumstances  the  disturbance  of  gustatory  sensibility 
is  only  a  disturbance  of  character,  a  particular  expression  of  the  pa- 
tient's general  pessimism.  But  in  any  case  it  does  not  appear  to  us  that 
gustatory  irritability — like  all  the  other  irritabilities — should  be  exalted 
into  the  position  of  an  autonomous  symptom. 

In  concluding  this  chapter  there  now  remains  for  us  to  give  a 
general  view  of  the  mechanism  of  psychic  hemianaesthesia  associated  with 
hemiansesthesia  of  general  sensibility.  One  knows  that  in  these  patients 
this  psychic  hemianaesthesia  is  constituted  by  the  presence  of  a  periph- 
eral auEesthesia  in  addition  to  a  narrowing  of  the  visual  fields,  with 
or  without  other  associated  ocular  disturbances,  and  by  a  diminution 
or  complete  suppression  of  auditory,  olfactory,  and  gustatory  acuteness. 

Although  it  is  possible,  in  a  certain  way,  to  get  an  idea  of  the 
mechanism  of  sensory  hemianassthesia,  which  has,  as  a  matter  of  fact,  a 
cerebral  topography,  and  at  the  same  time  what  we  might  almost  call  a 
mental  topography,  the  same  thing  is  not  true  for  psychic  anaesthesia. 
Here,  as  a  matter  of  fact,  the  disturbances  are  more  wide-spread,  and 
still  further — anatomically  speaking — ^their  peripheral  distribution  does 
not  correspond  in  any  way  to  any  cerebral  topography.  But,  do  they 
correspond  to  any  mental  topography?  In  other  words,  as  all  sensory 
stimuli  lead  up  by  anatomical  paths  to  bilateral  cerebral  stimulation, 
and  as  the  cerebral  topography  is,  as  a  matter  of  fact,  bilateral,  is  the 
mental  topography  unilateral?  Or,  if  one  so  prefers  to  put  it,  are 
there  fields  of  consciousness  which  respond  to  unilateral  psychic  stimuli  ? 
This  seems  evident  when  one  recalls  that  all  psychic  impressions  are 
accompanied  by  a  constant  idea  of  the  localization  or  the  position  of 
the  objects  which  have  caused  the  psychic  impression.  There  are,  more- 
over, ideas  and  judgments  which  in  a  more  or  less  automatic  manner 
largely  determine  our  equilibrium,  our  sense  of  direction,  and  all  our 
relations  with  the  external  world.  Therefore,  it  is  very  certain  that  all 
our  localizations  are  made  in  relation  to  the  median  line.  All  sensorial 
stimuli  which  are  susceptible  of  localization  are  situated  either  on 
the  right  or  on  the  left.  This  is  the  same  thing  as  saying  that  con- 
scious perceptions  correspond  to  a  certain  extent  to  a  unilateral  dis- 
tribution of  sensorial  sensibility.  In  these  conditions,  one  can  see  that 
the  inhibition  of  a  certain  number  of  mental  representations  may  lead 
to  the  creation  of  sensorial  hemianaesthesia.  But  one  can  also  see  how  pre- 
ponderant must  be  the  action  of  auto-suggestion  and  hetero-suggestion, 
as  it  is  a  question  here  of  mental  processes  which  are  already  complex. 
Emotion,  which  in  a  great  majority  of  cases  is  the  chief  factor  in  the 
production  of  hysterical  disturbances,  acts  as  a  whole.  Outside  of  the 
physical  phenomena  which  it  may  bring  about,  it  deprives  an  individual 
of  his  judgment,  of  his  will,  of  his  mental  equilibrium;  but  it  does 


MANIFESTATIONS  OF  SENSE  ORGANS.  167 

not  attack  mental  phenomena  as  complex  as  those  which  we  must  admit 
are  attacked  in  order  to  be  able  properly  to  interpret  psychic  hemi- 
anaesthesia. 

One  may,  however,  conceive  of  another  interpretation.  It  might  be 
possible,  psychologically  speaking,  for  the  functions  of  sensibiUty  and 
of  localization  to  be  so  closely  united  that  they  might  be  confused. 
What  the  hysteric  would  lose  under  these  conditions  would  not  be 
the  sensibility  of  the  right  half,  or  more  usually  the  left  half  of  his 
body,  but  rather  visual,  acoustic,  olfactory,  and  gustatory  hemi-sensi- 
bility.  What  would  be  lacking  to  him  would  be  the  whole  apparatus 
of  localization,  or,  if  one  so  prefer  to  call  it,  of  exterior  consciousness 
of  the  right  or  left  side,  with  all  the  general  and  sensorial  sensibilities 
which  belong  to  it.  One  would  thus  understand  the  curious  association, 
which  is  entirely  anti-anatomical,  if  one  might  so  call  it,  which  hysterics 
make  when  they  superimpose  upon  an  anaesthesia  of  general  sensibility 
the  psychic  disturbances  that  one  recognizes. 

All  this  evidently  is  pure  hypothesis,  whose  only  merit  as  an  hypoth- 
esis is  that  it  enables  one  to  take  a  rational  conception  of  things,  and 
may,  in  consequence,  have  some  chance  of  being  right. 


CHAPTER  X. 

NERVOUS  AND  PSYCHIC  MANIFESTATIONS  PROPERLY  SO  CALLED. 

Although  all  functional  manifestations  spring  directly  or  indirectly 
from  the  psyche,  it  does  not  follow  on  that  account  that  the  nervous 
apparatus  itself  has  nothing  to  do  with  them. 

We  have  already  seen  that  neuro-muscular  disturbances  and  dis- 
turbance of  the  sensibility  which  we  have  studied  constitute  the  nervous 
manifestations  properly  so  called.  Nevertheless,  a  certain  number  of 
points  remain  for  us  to  study,  and  we  shall  take  up  successively  in 
this  chapter — 

A.  Disturbances  of  sleep; 

B.  Headache; 

C.  Disturbances  of  the  reflexes; 

D.  Disturbances  of  speech; 

E.  Acquired  disturbances  of  psychological  functions; 

F.  Phobic  manifestations  fixed  upon  the  cerebrospinal  axis, 

A.  Disturbances  of  Sleep. — These  are  extremely  numerous  and  in- 
finitely varied  in  neurasthenics.  They  occupy  a  preponderant  place  in 
the  symptomatology.  They  are  the  source  of  a  whole  series  of  secondary 
disturbances.     Thus  we  ought  to  study  them  in  some  detail. 

It  is  far  from  ea^y  to  really  understand  these  troubles,  for,  at  the 
present  time,  there  is  no  theory  concerning  sleep, — or,  rather,  there  are 
too  many,  of  too  contradictory  a  nature. 

One  does  not  know  what  sleep  is,  but  there  is  no  author  who  does 
not  believe  that  he  has  the  right  to  define  insomnia.  One  takes  it  for 
granted  that  it  has  a  pathological  physiology,  while  ignorant  of  its 
normal  physiology.  Hence,  the  pathogeny  of  sleep  disturbances  be- 
comes, to  a  certain  degree,  individual.  This  man — ^we  speak,  of  course, 
only  of  purely  neuropathic  conditions — does  not  sleep  because  he  is 
under  too  great  tension,  and  that  man  because  he  is  too  much  relaxed, 
another  has  too  much  or  too  little  acidity  in  his  urine,  a  fourth  is  so 
feeble  that  he  cannot  tire  himself  sufficiently,  etc. 

It  seems  to  us  that,  if  one  wants  to  get  a  little  more  definite  idea 
concerning  the  mechanism  of  sleep  disturbances  in  the  neurasthenic, 
it  ought  to  be  enough  to  acquaint  oneself  with  what  occurs  in  the 
healthy  man.  The  study  of  conditions  which  permit  sleep  to  be  regular, 
the  search  for  causes  which  may  occasionally  disturb  it,  may  be  able, 
it  seems  to  us,  to  furnish  sufficiently  exact  ideas  to  explain  the  great 
majority  of  irregularities  which  sleep  may  undergo  in  the  course  of 
the  psychoneuroses. 

First  of  all,  there  is  no  doubt  that  sleep  is  a  natural  function  of 
168 


NERVOUS  AND  PSYCHIC  MANIFESTATIONS.  169 

the  body,  and  that  a  series  of  waking  and  sleeping  states  forms  as 
necessary  a  rhythm,  for  example,  as  the  contraction  and  relaxation  of 
a  muscle.  Sleep  is  a  general  function  of  all  organized  beings.  Accord- 
ing to  some  naturalists,  it  exists  even  among  plants,  and  there  is 
perfectly  rhythmic.  Among  animals,  psychic  life  seems  to  be  limited 
to  their  bodily  life,  sleep  appears  with  the  disappearance  of  all  peripheral 
stimuli  and  all  demands  of  organic  life.  As  far  as  the  animal 
is  concerned,  the  psychological  doctrine  of  sleep  of  Claparede  is  quite 
exact.  According  to  him,  sleep  constitutes  a  true  '*  reaction  of  dis- 
interestedness." The  dog  that  has  eaten  a  full  meal,  having  no  interest 
in  any  action  outside  of  himself  other  than  the  needs  of  his  body, 
sleeps.  It  is  the  same  way  with  a  very  young  child.  In  the  case  of 
the  latter  one  might  almost  say  that  sleep  is  the  natural  condition,  out 
of  which  he  emerges  when  he  is  hungry  or  when  some  peripheral  stimulus 
awakens  him.  But,  in  proportion  as  the  child 's  age  increases,  things  are 
modified.  Instead  of  sleeping  eighteen  or  twenty  hours  a  day,  he  does 
not  sleep  more  than  fourteen,  then  twelve,  and  when  he  becomes  an 
adult  his  sleep  will  be  reduced  to  the  smallest  amount  necessary,  which 
varies,  however,  according  to  individuals. 

Between  the  time  when  sleep  was,  in  a  sort  of  fashion,  the  natural 
state  of  the  child,  and  the  time  when  in  adult  life  sleep  is  reduced  to 
what  is  necessary,  what  has  taken  place?  One  of  course  thinks  right 
away  of  the  lessened  organic  expenditure  of  the  adult.  It  is  probably 
true  that  this  phenomenon  plays  a  rôle,  and  that  to  a  certain  degree  sleep 
is  proportionate  to  the  organic  expenditure.  But  for  certain  individuals, 
and  particularly  for  adults  of  the  same  age,  this  expenditure  may  be 
considered  as  a  constant  factor;  nevertheless,  sleep  varies  according  to 
the  individual.  Still  further,  with  the  same  organic  life,  sleep  may 
vary  in  a  given  individual  from  one  day  to  another.  It  seems  to  us, 
therefore,  that  this  element  of  organic  expenditure  must  be  eliminated. 
On  the  other  hand,  in  those  animals  which  from  the  day  of  their  birth 
are  capable  of  living  by  themselves,  particularly  birds,  this  difference 
between  the  sleep  of  the  new-bom  and  that  of  the  adult  is  much  less 
marked. 

In  reality,  what  seems  to  us  the  essential  thing  that  leads  to  such  a 
variation  is  the  progressive  development  of  mental  life. 

Sleep  henceforth  seems  to  us  to  be  limited  by  three  orders  of  facts, 
— namely,  the  demands  of  bodily  life,  peripheral  stimuli,  and  what  we 
might  call  mental  stimuli. 

These  three  factors  have  a  different  importance  according  to  differ- 
ent individuals.  With  the  farm  laborer,  accustomed  to  hard  work,  and 
with  scarcely  any  tendency  toward  meditation,  it  would  chiefly  be  the 
peripheral  stimuli  which  would  affect  his  sleep.  He  falls  asleep  at  night 
and  wakes  with  the  returning  day.  With  an  intellectual  man,  sleep  will 
be  limited  by  psychological  stimuli.  The  sleep  of  some  individuals 
will  be  more  particularly  affected  than  others  by  the  demands  of  their 


170  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

bodies,  and  they  will  find  it  very  difficult  to  fall  asleep  if  their  stomachs 
are  not  satisfied,  and  will  wake  up  because  they  are  hungry.  But  with 
all^  the  laborer,  the  savant,  and  the  epicure,  sleep  will  remain  a  neces- 
sary function,  an  irresistible  need  of  the  body.  Whence  comes  this 
need  of  sleep  ? 

When  the  necessity  for  sleep  appears,  two  different  kinds  of  facts 
come  into  play.  On  the  one  hand,  habit  seems  to  step  in,  and  arranges  it 
so  that  at  a  certain  hour,  under  the  usual  circumstances  of  life,  after  we 
have  passed  through  the  same  daily  succession  of  deeds  and  movements, 
the  idea  of  sleep  comes  to  us. 

Often  the  need  of  sleep  appears  earlier  than  is  habitual,  when  the 
day  has  been  fatiguing,  or  when  our  daily  duty  has  necessitated  great 
mental  tension.  Inversely,  all  causes  of  mental  excitation  delay  the 
appearance  of  the  idea  of  sleep.  Emotion,  preoccupations,  and  the 
cerebral  tension  of  the  present  moment,  not  of  some  past  time,  inhibit 
the  need  of  sleep. 

Up  to  what  point  may  this  need  be  inhibited?  It  is  one  of  the 
characteristics  of  man  to  be  able  to  act  upon  his  functions  by  his  will. 
This  is  the  very  basis  of  the  psychic  origin  of  so  many  objective  dis- 
turbances. Man  may  control  his  own  sleep,  and  in  certain  circumstances 
he  may  delay  it  indefinitely.  Does  not  one  see  people  going  for  weeks, 
even  months,  without  sleeping  while  caring  for  some  relative, — a  sick 
father,  a  mother,  or  a  husband?  Their  psychic  tension  and  their  de- 
votion are  sufficient  to  inhibit  sometimes  all  desire,  even  all  need  of 
sleep. 

It  happens,  however,  that,  in  spite  of  the  person's  will,  he  may  be 
taken  with  what  one  would  call  an  imperative  desire  to  sleep,  which  he 
is  incapable  of  resisting. 

What  we  conceive  as  happening  to  such  a  person  as  we  have  just 
described,  who  is  nursing  another,  is  that  his  will  at  a  given  moment 
becomes  deficient,  and  that  the  instinctive  need  gets  the  upper  hand.  He 
does  not  resist  it  then,  any  more  than  the  starving  or  thirsting  man 
could  resist  the  need  of  taking  food  or  of  drinking. 

In  other  cases,  after  intense  physical  work,  having  gone  far  beyond 
what  one  habitually  does  or  is  capable  of  doing,  one  may  be,  as  it  were, 
overcome  by  sleep.  The  work,  in  order  to  be  finished,  has  necessitated 
a  considerable  expenditure  of  energy,  and  the  invincible  need  of  sleep 
marks  the  limit  of  possible  voluntary  tension. 

On  the  other  hand,  sleep  may,  to  a  very  large  degree,  be  a  matter  of 
education.  Just  as  an  individual  who  has  restrained  himself  from  eat- 
ing may,  even  though  he  be  the  most  normally  constituted  of  beings, 
gradually  lose  his  appetite,  in  the  same  way  a  subject  who  allows  him- 
self only  a  limited  amount  of  sleep,  or  goes  without  sleeping  at  all, 
gets  to  the  point  where  he  is  no  longer  able  to  sleep. 

To  sum  up,  the  moment  at  which  the  need  of  sleep  appears  is 
determined  by  habit,  whether  settled  or  accidental.    If  the  need  of  sleep 


NERVOUS  AND  PSYCHIC  MANIFESTATIONS.  171 

appears  to  correspond  to  an  organic  demand,  this  demand  may  be  re- 
tarded by  the  intervention  of  the  will,  by  some  mental  stimulus,  or  more 
simply  by  distraction,  which  is  here  only  a  form  of  excitement.  The 
need  of  sleep  only  becomes  imperative  when  the  ** psychic  tonus"  is 
exhausted. 

If  we  go  back  to  the  comparison  already  made  between  the  succession 
of  waking  and  sleeping  and  the  succession  of  contractions  and  relaxa- 
tions of  a  muscle  while  working,  we  see  that  all  the  terms  which  rule  the 
one  may  be  applied  to  the  other.  In  a  given  subject  a  definite  number 
of  contractions  creates  the  need  of  rest.  The  will  may  prolong  the 
effort,  but  there  comes  a  moment  when  it  itself  fails,  and  where  it 
becomes  a  physical  necessity  to  stop  work. 

With  education  and  training,  or  on  the  contrary  with  a  too  pro- 
longed muscular  rest,  the  limit  of  possible  work,  which  on  the  other 
hand  has  personal  voluntary  energy  as  well  as  a  factor,  will  either 
increase  or  diminish. 

If,  now,  we  take  a  subject  who  has  yielded  to  the  normal  non- 
imperative  need  of  sleep,  how  does  he  pass  from  his  waking  state  to  the 
state  of  sleep  ?  This  passage  is  performed  in  an  infinite  variety  of  ways, 
according  to  the  subject,  and  in  the  same  individual  according  to  the 
circumstances.  There  are  some  people  who  fall  asleep  the  moment  their 
heads  touch  the  pillow.  There  are  others,  and  a  very  great  number, 
who  do  not  fall  asleep  without  having  gone  through  a  certain  amount 
of  mechanical  intellectual  work,  during  the  course  of  which  they  feel 
themselves  ** gradually  getting  off  to  sleep."  To  this  group  belong  the 
great  number  of  people  who  cannot  go  to  sleep  without  reading.  A 
question  of  habit  one  will  say,  but  this  habit  is  often  legitimate.  If,  on 
the  one  hand,  reading  induces  sleep  by  letting  down  the  psychic  tension, 
its  object  on  the  other  hand,  is  often  to  dull  consciousness  progressively 
in  subjects  who  are  habitually  excited,  and  whose  psychological 
automatism  is  continually  introducing  new  combinations  of  ideas  into 
the  mind.  Here  we  are  also  on  the  frontiers  of  pathology,  and  the  very 
people  who  in  the  ordinary  course  of  life  feel  the  need  of  coaxing  sleep, 
find  it  spontaneously  when  they  are  away  on  a  vacation  in  the  country, 
and  at  rest  and  free  from  all  preoccupations  and  cares. 

Normal  sleep,  therefore,  is  spontaneous  sleep,  constituting,  as 
Claparède  has  said,  a  true  reaction  of  disinterestedness.  But  it  cannot 
occur  without  the  loss  of  voluntary  or  involuntary  psychologic  con- 
sciousness. 

Now  that  our  subject  has  fallen  asleep,  his  sleep  will  either  be  deep, 
slight  or  heavy,  calm  or  restless.  By  what  will  these  qualities  of  sleep 
be  determined?  It  is  evident,  after  what  we  have  just  said,  that  either 
painful  or  simply  instinctive  demands  upon  the  body  and  slight  or 
marked  peripheral  stimuli  will  have  a  very  decided  bearing  upon  the 
quality  of  sleep.  But  what  will  also  affect  it  will  be  the  demands  made 
upon  consciousness  by  the  psychologic  automatism,  which  preserves  its 


172  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

independence  in  sleep.  These  demands' are  the  dreams  which  one  does 
not  remember,  as  well  as  those  which  one  does  remember,  and  also  night- 
mares. There  are  also  dreams  which  come  to  order,  which  enable  certain 
people  to  wake  up  at  the  time  that  they  have  fixed.  But  it  is  very  certain 
that,  in  all  this  ascending  gradation,  sleep  may  be  more  or  less  affected 
by  incursions  of  the  psychological  automatism  into  the  domains  of 
consciousness,  which  may  be  so  slight  that  no  traces  of  them  remain  in 
the  memory,  except  the  impression  that  the  subject  has  on  waking  that 
his  sleep  was  not  as  restful  as  it  should  have  been.  The  rôle  played  by 
these  '  '  doings  in  dreamland  '  '  seems  to  us  under  certain  circumstances  to 
be  fraught  with  great  importance. 

Now  for  awakening.  This  may  be  sudden  or,  on  the  contrary, 
gradual.  It  varies  according  to  constitutional  or  acquired  conditions. 
There  are  many  people  who  are  so  made  that  from  their  earliest  child- 
hood they  are  never  reaUy  wide  awake  and  actively  conscious  until  a 
certain  time  after  waking.  There  are  others  in  whom  the  same  phenom- 
enon is  an  acquired  habit.  These  are  those  who  are  stimulated  by  life, 
and  who  as  the  day  goes  on  gradually  reach  a  state  of  complete  physical 
and  intellectual  activity.  It  is  cruelly  hard  for  them  to  wake  up,  and  they 
have  to,  as  it  were,  lash  themselves  to  go  about,  to  work,  to  think,  even  to 
make  themselves  get  up.  It  is  really  a  question  of  an  abnormal  symptom. 
But  it  exists  in  a  great  many  people  whose  lives  taken  as  a  whole  are  per- 
fectly normal,  and  in  this  lies  the  interest  of  the  fact,  as  we  shall  see 
further  on. 

Such  being  our  conception,  not  of  the  intimate  nature  nor,  of  course 
(which  goes  without  saying),  of  the  physiology  of  sleep,  but  rather  of 
some  of  the  conditions  which  control  it,  we  may  pass  on  to  the  study  of 
the  disturbances  of  sleep  which  may  be  seen  in  the  course  of  the 
psychoneuroses. 

First  of  all,  we  must  make  one  reservation.  It  is  self-evident  that 
the  act  of  sleeping  presupposes  a  certain  number  of  organic  conditions, 
and  that  organic  afflictions  of  various  kinds  may  disturb  the  sleep  of  the 
neurasthenic  as  it  might  any  other  individual  who  was  attacked  in  the 
same  manner. 

A  neurasthenic  could  quite  evidently  be  a  neurasthenic  and  some- 
thing else  besides.  He  could  be  arteriosclerotic,  a  victim  of  Bright 's 
disease,  a  cardiac,  an  asthmatic,  etc.  He  could  even  be  merely  strung 
up  or  intoxicated,  and  for  that  reason  have  his  sleep  affected.  We 
would  not  dream  of  denying  this.  But  we  believe  that  it  is  the  ex- 
ception, and  that,  in  the  great  majority  of  cases,  sleep  disturbances 
presented  by  this  class  of  patients  belong  wholly  and  exclusively  to  the 
neuropathic  affections  from  w^hich  they  are  suffering. 

Insomnia  is  the  most  frequent  symptom  of  which  neurasthenics 
complain.  It  constitutes  in  itself  an  extremely  variable  phenomenon. 
Sometimes  the  insomnia  is  absolute.  Whole  nights  will  pass  without 
a  moment  *s  loss  of  consciousness.     Sometimes  it  is  the  need  of  sleep 


NERVOUS  AND  PSYCHIC  MANIFESTATIONS.  173 

which  is  lacking.  The  patients  feel  themselves  to  be  excited  and  nervous 
and  cannot  fall  asleep.  At  other  times  the  patient  has  a  great  desire 
to  sleep.  He  goes  to  bed,  but  cannot  really  go  sound  asleep  for  several 
hours.  One  sees  patients  of  this  kind  going  to  bed  at  ten  or  eleven 
o'clock  at  night  and  falling  asleep  toward  four  or  five  in  the  morning. 
Two  phenomena  may  then  occur.  Sometimes  the  sleep  will  be  simply 
out  of  place,  and  the  patient  once  he  has  fallen  asleep  will  rest  for  a 
reasonable  length  of  time.  Sometimes  he  w^ll  awaken  at  his  regular 
time,  and  will  thus  have  considerably  reduced  his  daily  allowance  of 
sleep,  when  there  was  no  necessity,  so  far  as  his  day  was  concerned,  for 
him  to  waken  and  get  up,  and  when  he  would  have  liked  to  prolong  his 
rest. 

There  are  patients  w^ho  fall  asleep  easily,  but  who  awaken  in  a  very 
short  time.  There  are  some  who  get  into  the  habit  of  waking  in  half 
an  hour,  an  hour,  or  two  hours.  Once  awake  they  cannot  go  to  sleep 
again. 

Certain  subjects  complain  of  broken  sleep.  They  get  to  sleep  with 
more  or  less  difficulty,  only  to  waken  shortly  afterward,  and  to  have 
trouble  in  falling  asleep  again,  and  waking  again,  and  so  on.  Under 
other  circumstances  patients  say  that  it  is  the  quality  of  their  sleep 
which  is  disturbed.  This  one  complains  of  sleeping  too  lightly,  that  one 
of  sleeping  too  heavily,  while  another  is  too  restless  in  his  sleep.  There 
are  some  people  who  even  find  that  they  sleep  too  much  and  too  soundly  ! 

Perhaps  the  commonest  of  these  daily  observations  consists  in  the 
statement  made  by  patients  that  "their  sleep  is  not  restful."  They 
wake  up  as  tired  as  when  they  went  to  bed,  if  not  more  so. 

Briefly  put,  these  are  the  troubles  of  which  patients  complain.  As 
to  the  pathogeny  which  they  attribute  to  them  and  the  morbid  relations 
which  they  establish,  they  are  numerous  and  most  fantastic.  Although 
it  goes  without  saying  that  sleep  may  be  better  or  worse,  according  to 
the  surroundings,  the  air,  the  temperature,  or  according  to  what  one 
has  just  been  eating,  or  to  the  kind  of  bed,  etc.,  yet  one  can  not  imagine 
how  much  may  be  made  of  these  causes  and  associations  by  patients. 
Changing  the  position  of  the  bed  or  couch  by  an  angle  of  a  few  degrees, 
a  slight  modification  of  temperature,  imperceptible  barometric  or 
hygrométrie  variations, — these  would  be  enough  to  prevent  them  from 
sleeping  or  to  make  them  sleep  poorly.  The  slightest  change  in  their 
diet  or  modification  in  their  night  clothes  or  in  their  bed  covering  is 
enough  to  establish  insomnia.  We  might  go  on  indefinitely  with  the 
list  of  ''causes."  This  enumeration  only  proves  one  thing — ^namely, 
that  insomnia  has  a  moral  as  well  as  physical  effect  upon  the  patients 
who  suffer  from  it.  It  haunts  their  imaginations,  and  they  have  no 
peace  unless  they  can  attribute  it  to  some  external  cause,  which  con- 
sequently is,  according  to  their  idea,  modifiable.  It  is  true  that  the 
cause  is  susceptible  of  modification,  but  it  is  mental. 

Different  mechanisms  may  come  into  play.     Insomnia  may  be  the 


174  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

result  of  education.  A  woman  has,  we  will  say,  been  taking  care  of  her 
parents  or  an  invalid  child  for  years.  The  beloved  one  finally  dies, 
taking  with  him,  as  far  as  our  patient  is  concerned,  all  interest  in  life. 
She  feels  herself  alone  in  the  world  and  is  lost  and  discouraged.  She 
eats  very  little,  becomes  depressed,  and  grows  thin.  She  feels  that  in 
order  to  regain  her  strength  she  is  in  need  of  restful  sleep,  which  would 
at  the  same  time  be  a  sleep  of  oblivion.  But,  in  spite  of  all  she  can  do, 
she  keeps  for  a  very  long  time,  sometimes  indefinitely,  the  habits  of 
sleep  that  she  formed  during  those  years. 

In  the  case  of  indefatigable  workers  and  trained  nurses  who  have 
ascetically  deprived  themselves  of  sleep,  the  same  facts  may  be  observed. 

The  interesting  fact  lies  less  in  the  acquisition  of  a  bad  habit  formed 
through  years  which  is  easy  to  conceive,  than  in  the  acquirement  of 
this  habit,  which  is  sometimes  very  rapid,  under  given  conditions. 
"We  have  seen  patients  of  this  kind  in  whom,  the  rhythm  of  sleep  having 
been  voluntarily  modified  for  only  a  few  weeks,  seemed  to  be  almost 
definitely  changed.    This  was  because  a  new  mechanism  intervened. 

Here,  for  example,  is  a  man  of  some  forty  years,  who  during  six 
weeks  nursed  his  wife,  who  died  of  a  severe  case  of  typhoid.  During 
this  period  he  took  only  two  or  three  hours  of  rest  each  night,  and 
always  at  the  same  time,  between  two  baths  given  to  the  patient  at  ten 
at  night  and  two  o'clock  in  the  morning.  After  the  death  of  his  wife, 
for  several  months  he  was  not  able  to  get  to  sleep  except  at  the  same 
hours  and  for  the  same  length  of  time.  It  would  really  seem  that  the 
time  which  he  had  spent  in  sitting  up  at  night  had  been  too  short  to 
have  permitted  education  or  habit  to  be  the  cause.  One  could  under- 
stand it  if  after  his  wife's  death  he  was  afflicted  with  absolute  insomnia 
by  the  obsession  of  memory;  but  he  did  nothing  of  the  kind,  for,  as  a 
matter  of  fact,  he  would  fall  asleep  at  a  comparatively  early  hour  and 
without  much  difficulty.  We  think  that  here  we  have  to  do  with  facts 
in  which  the  psychological  automatism  is  the  cause.  Our  patient  was 
very  much  in  love  with  his  wife.  He  nursed  her  with  absolute  devotion. 
He  was  absorbed  in  every  detail  of  the  care  which  he  gave  to  her.  His 
mind  was  continually  in  a  state  of  tension,  so  that  he  should  forget 
none  of  the  treatment  which  was  to  be  given  or  of  the  observations  to 
be  made.  It  is  very  evident  that  there  was  established  in  his  psycho- 
logical automatism  a  whole  series  of  strong  associations,  of  which  a 
certain  number  had  to  do  with  the  appeal  to  his  consciousness,  which 
wakened  him  at  the  end  of  two  or  three  hours.  The  thing  that  seems 
to  us  to  act  in  cases  of  this  kind  is  the  recall  of  consciousness  due  to 
functioning  of  the  psychologic  automatism.  It  is  a  mechanism  identical 
to  that  which  makes  a  healthy  man,  in  the  immense  majority  of  cases,  no 
matter  whether  his  sleep  has  been  sufficient  or  insufficient,  waken 
every  day  at  the  same  hour.  But,  while  in  a  healthy  man  this  mechan- 
ism may  easily  be  set  aside  to  allow  him  a  chance  to  take  compensatory 
rest,  it  is  firmly  established  in  our  patient,  and  this  is  because  all  the 


NERVOUS  AND  PSYCHIC  MANIFESTATIONS.  175 

automatic  ideas  which  had  to  do  with  his  waking  are  bound  up  in  the 
memory  of  his  wife,  and  in  ideas  connected  with  her,  and  that  he  thinks 
continually  all  day  long  of  the  loss  which  has  come  to  him. 

Here  it  is  a  question  merely  of  a  habit  which  is  in  some  respects 
organic,  of  the  quantitative  diminution  of  the  need  of  sleep;  it  is,  if 
one  might  so  call  it,  a  psychological  habit  which  is  at  the  bottom  of  it, 
and  which  the  thoughts  and  memories  of  daily  life  only  tend  to 
reinforce. 

Outside  of  cases  where  the  patients  sleep  less  because  they  have 
formed  a  habit  of  needing  less  sleep,  it  is  the  intervention  of  the  psycho- 
logical automatism  which  seems  to  us  to  play  an  important  rôle  in  the 
early  wakening,  the  broken  sleep,  or  the  restless  sleep  of  which  so  many 
neurasthenics  complain.  These,  for  reasons  that  we  shall  have  to 
analyze  further  on,  while  they  may  at  the  same  time  suffer  from  de- 
pression from  the  point  of  view  of  consciousness  are  nearly  always 
excited  from  the  point  of  view  of  the  subconscious  automatism.  Ideas 
penetrate  consciousness  involuntarily  with  the  greatest  facility.  It  is  the 
same  mechanism  of  certain  slight  obsessions  which  one  may  discover  in 
them,  and  what  goes  on  during  their  waking  hours  continues  to  occur 
while  they  are  sleeping;  hence  the  broken  sleep,  the  numerous  dreams^ 
and  the  restlessness. 

In  certain  people,  who  have  been  accidentally  awakened  once  by 
phenomena  of  the  same  kind,  the  fear  of  being  awakened  again  which 
they  have  been  nursing  all  day,  is  enough  to  furnish  the  cause  and  the 
explanation  of  the  tendency  to  wake. 

This  is  a  fact  which  occurs  very  often  among  those  who  have  sleep 
phobias.  They  do  not  sleep  because  they  are  afraid  that  they  will  not 
sleep.  But  what  we  find  most  often  in  these  cases  is  the  difficulty  that 
the  patients  have  in  getting  to  sleep.  And  if  they  cannot  get  to  sleep 
it  is  because  in  their  case  and  from  the  fact  that  their  thoughts  are 
continually  focussed  on  the  idea  of  wanting  to  go  to  sleep,  that  the 
impossibility  of  succeeding  in  losing  their  voluntary  consciousness  which, 
as  we  have  seen,  constitutes  an  essential  condition  of  sleep,  occurs. 

Here  are  two  examples: 

Mr.  X.,  fifty-two  years  of  age,  a  musician  of  parts,  when  we  saw  him 
for  the  first  time  had  passed  fifty-six  nights  without  sleeping.  All 
hypnotic  medications — ^morphine,  opium,  chloral,  bromides,  etc. — ^had 
been  given  without  producing  anything  more  than  a  passing  drowsiness. 
He  had  been  looked  upon  as  a  toxic  case  or  one  of  hypertension,  and 
treatment  and  medicines  had  been  ordered  with  this  in  view. 

The  starting-point  of  this  prolonged  insomnia  went  back  to  some 
disturbance  of  sleep  caused  by  very  strong  emotions.  But  when  we 
saw  the  patient  these  emotions  were  no  longer  a  causative  agent,  and 
it  was  only  the  persistence  of  his  insomnia  that  disturbed  him.  The  day 
after  our  first  interview  with  this  patient,  we  received  a  card  from 
him  on  which  he  had  written,  **A  miracle,  doctor:  I  have  slept  a  little.'* 


176  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

He  was  modest  in  his  appreciation,  for  upon  inquiry  we  learned  that 
he  had  slept  soundly  and  well  for  ten  consecutive  hours,  without 
waking  once. 

Now,  what  had  we  done?  We  had  ordered  nothing,  and  we  had 
been  content  to  suppress  four  things, — namely,  his  medicines,  his  treat- 
ment, his  electricity,  and — ^his  sister. 

What  happened  in  fact  in  his  case  was  extremely  simple.  When  he 
had  had  his  accidental  insomnia,  our  subject  was  in  the  act  of  ''com- 
posing." It  goes  without  saying  that  his  sleep  disturbances  naturally 
affected  his  power  of  creation.  He  had  been  very  much  concerned  by 
this  and  was  extremely  upset.  His  sister,  who  lived  with  him,  had 
shared  his  uneasiness.  Our  patient,  from  that  time  on,  always  went 
to  bed  with  the  same  idea,  "Am  I  going  to  go  to  sleep?"  He  would 
go  to  bed,  read  a  few  minutes,  put  out  his  electric  light,  and  wait. 
Naturally  sleep  could  not  come  so  quickly.  At  the  end  of  a  scant 
quarter  of  an  hour,  he  would  turn  on  the  electricity,  read  again,  and 
turn  it  out  again,  and  would  repeat  this  performance  all  through  the 
night.  Meanwhile  his  sister,  who  occupied  the  adjoining  room,  hearing 
him  move,  would  come  every  once  in  a  while  to  open  his  door,  and  ask, 
*' Joseph,  aren't  you  asleep?"  and  then  would  condole  with  him  on 
receiving  the  inevitably  negative  reply.  Once  removed  from  his  sister 
and  deprived  of  all  means  of  lighting  his  room,  and  also,  let  us  add, 
reassured  concerning  the  mechanism  of  his  insomnia,  this  patient  was 
able  to  get  back  the  sleep  which  he  believed  lost  to  him,  in  the  manner 
we  have  described. 

Another  patient  whom  we  have  seen  complained  of  insomnia  which 
was  nevertheless  very  irregular.  He  had  established  a  very  curious 
series  of  systematizations.  His  sleep  at  night,  he  said,  depended  on 
impressions  of  the  day.  He  could  tell  in  the  morning  whether  or  not 
he  would  sleep  the  next  night.  In  this  way,  when  he  went  to  bed  he 
had  a  conviction  of  his  inability  to  sleep,  or  the  possibility  of  its  com- 
ing, which  determined  his  condition  for  the  night.  When  he  was  sure 
that  he  would  not  sleep,  he  would  walk  up  and  down  his  room,  read 
and  think  about  things,  and  would  thus  get  through  the  night  without 
too  much  discomfort.  When,  on  the  contrary,  he  knew  that  he  was 
going  to  sleep,  he  would  tranquilly  go  to  bed,  and  would  fall  asleep 
comfortably.  Otherwise  his  health  was  excellent,  and  he  was  in  per- 
fectly good  humor.  He  was  a  good  liver  and  practised  no  privations, 
and,  when  the  chance  presented  itself,  he  thought  nothing  of  taking  a 
good  long  sleep  in  the  daytime  to  make  up  for  his  loss. 

One  thus  sees  that  in  cases  of  this  kind  conscious  preoccupation  may 
come  in  to  disturb  sleep.  If  in  this  instance  the  preoccupation  was  of  the 
kind  that  concerned  sleep  itself,  under  other  circumstances  it  would  be 
all  the  emotions  and  obsessive  thoughts  which  would  arise,  and  which 
as  soon  as  the  patient  was  in  a  more  or  less  voluntary  state  of  conscious- 
ness would  hinder  sleep  from  coming,    Here  we  have  the  chief  reasons 


NERVOUS  AND  PSYCHIC  MANIFESTATIONS.  177 

for  insomnia  in  neurasthenics.  Either  the  emotional  cause  itself  which 
has  engendered  their  neurasthenia  persists,  or  else  it  is  the  idea  of  their 
condition  which  haunts  them. 

Thus,  in  patients  suffering  from  insomnia  the  return  of  sleep  is  one 
of  the  chief  signs  of  improvement,  not  so  much  because  his  recovered 
sleep  permits  the  patient  to  improve,  but  because  its  return  proves  that 
the  patient  is  less  preoccupied  and  less  uneasy  about  his  health,  or,  in  a 
word,  that  his  moral  state  is  better. 

To  sum  up,  outside  of  the  phenomena  of  habit  which  are  apt  to  be 
to  some  degree  superadded,  the  neurasthenic  does  not  sleep  because  he 
has  lost  the  faculty  of  being  able  to  either  voluntarily  or  involuntarily 
stop  thinking.  He  does  not  sleep  because  he  thinks,  and,  if  his  thought 
is  often  involuntary  on  account  of  appeals  made  to  his  consciousness  by 
a  psychologic  automatism  which  is  no  longer  under  restraint,  his  thought 
also  is  often  voluntary  because  the  pessimistic  moral  condition  of  these 
patients  makes  them  abnormally  interested  in  all  their  depressing  pre- 
occupations. 

The  act  of  waking' in  these  neurasthenics  may  be  the  origin  of  all 
sorts  of  disturbances.  The  impression  which  they  get  at  that  time  may 
fix  their  mentality  all  through  the  day,  and  thus  play  a  rôle  in  the 
persistence  of  the  appearance  of  many  secondary  troubles.  We  are 
not  at  all  sure  but  that  the  fatiguability  of  certain  patients  may  not 
be  due  in  part  to  the  impression  of  fatigue  which  they  feel  on  waking. 

This  fatigue  on  waking  may,  in  some  cases,  be  legitimate.  When, 
under  the  influences  which  we  have  tried  to  bring  out,  the  patient's 
sleep  has  been  poor,  broken,  or  restless,  it  is  not  astonishing  that  our 
subject  should  feel  when  he  wakes  that  he  had  not  had  sufficient  rest. 
But  there  are  neurasthenics  who  sleep  well,  and  who  nevertheless  ex- 
perience the  classic  feeling  that  they  are  more  tired  in  the  morning 
than  at  night,  and  who  henceforth  will  pass  their  whole  day  under  this 
impression,  which  is  peculiarly  inhibitive  to  every  kind  of  effort.  Now, 
generally,  if  one  questions  these  patients  about  the  periods  of  their 
life  before  they  developed  this  neurasthenic  condition,  they  will  tell 
you  that  this  sensation  is  one  which  they  have  felt  always  or  at  any 
rate  for  a  very  long  time  before  they  became  avowed  neurasthenics. 
We  have  already  said  that  this  was  in  fact  nothing  but  an  affectation, 
w^hich  was  sometimes  constitutional  and  often  acquired,  by  people  who 
had  fallen  into  the  habit  of  doing  so  little  that  their  chief  interest  in 
life  resolved  itself  into  thinking  of  themselves.  It  is  very  certain  that 
the  conditions  which  bring  about  this  state  of  being — preoccupation, 
care,  emotions,  obsessions  of  overwork  which  force  patients  to  take  up 
their  life,  get  hold  of  themselves,  and  to  be  in  a  state  of  continual  excite- 
ment in  order  to  preserve  their  existence  along  its  normal  lines — ^are 
the  very  conditions  which  frequently  bring  on  the  neurasthenic  state. 
There  is  nothing  astonishing,  therefbre,  in  the  fact  that  such  a  phenom- 
enon— either  for  constitutional  reasons,  or  for  accidental  reasons,  or 
12 


178  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

depending  on  the  manner  of  living — should  be  found  almost  constantly 
in  neurasthenics.  But,  outside  of  legitimate  fatigue,  in  connection  with 
insufficient  sleep,  the  thing  that  becomes  abnormal  in  these  patients  is 
the  conservation  of  the  impression.  Formerly  they  did  not  even  take 
it  into  consideration,  they  would  go  on  just  the  same,  and  they  could  do 
their  daily  work  just  as  well  or  better  than  others.  Now,  however,  their 
minds  have  become  fixed  on  this  impression  of  fatigue,  they  are  obsessed 
concerning  it,  and  can  make  it  a  factor  of  every  succeeding  stage  of 
the  day. 

It  is  in  this  way  that  the  neurasthenic's  fatigue  on  awaking  resolves 
itself  into  two  kinds, — ^namely,  true  fatigue  caused  by  disturbed  sleep 
for  psychological  reasons,  on  the  one  hand,  and,  on  the  other  hand,  the 
fixation  of  the  patient's  ideas  on  impressions  which  have  existed  for  a 
long  time. 

Disturbances  of  sleep  as  hysterical  manifestations  are  no  less 
numerous.  Insomnia  may  exist  among  hysterics  as  among  all  neuras- 
thenics, but  its  mechanism  is  generally  quite  different.  Without  his 
being  able  to  bring  into  play  the  rôle  of  education  or  of  habit,  the 
hysteric  loses  his  idea  of  sleep  for  a  time,  which,  however,  is  generally 
quite  brief.  He  does  not  feel  the  need  of  it,  he  does  not  pursue  the 
sleep  which  evades  him.  He  simply  does  not  try  to  sleep.  He  is  in  a 
condition  of  continued  wakefulness.  Sometimes  his  insomnia,  we  must 
not  fail  to  add,  is  purely  subjective,  and  he  pretends  not  to  sleep,  and, 
when  we  inquire  a  little  more  particularly,  we  find  that  in  reality  he  is 
not  sleepless.  Is  this  a  question  of  simulation?  It  does  not  seem  so  to 
us.    It  is  simply  an  erroneous  conviction. 

On  the  other  hand,  when  it  comes  to  not  sleeping  in  the  cases  of 
neurasthenics  or  hysterics,  or  even  accidental  insomnias  in  healthy 
people,  the  hours  when  they  do  not  sleep,  when  every  one  else  is  sleeping 
around  them,  always  seem  peculiarly  long.  The  human  mind  is  only 
conscious  of  time  through  association  of  ideas.  In  the  domain  of  pure 
subjectivity  the  idea  of  time  is  quite  uncertain,  and  is  only  measured 
by  the  number  of  impressions  experienced  or  the  successive  states  of 
consciousness  which  are  registered.  Therefore,  during  hours  of  sleep- 
lessness, in  the  absence  of  all  external  interests  and  the  absence  of  all 
voluntary  choice  of  ideas,  the  domain  of  consciousness  is  confused  with 
that  of  the  psychologic  automatism  which  is  on  much  greater  tension 
than  usual.  Thus,  without  order  and  without  cohesion,  following  the 
type  of  automatic  psychological  associations,  ideas  come  rushing  in  and 
out  of  the  mind  during  the  hours  of  insomnia.  It  seems  as  if  one  had 
lived  through  whole  days  when  only  a  few  minutes  have  gone  by. 

The  physician  will  therefore  always  do  well  to  be  on  his  guard,  for 
the  patient  who  pretends  that  he  *'has  not  closed  his  eyes"  has  often 
slept  soundly  all  night.  This  is  true  for  a  normal  man;  it  is  also  true 
for  the  neurasthenic,  and  even  more  apt  to  be  the  case  with  the  hysteric, 
by  reason  of  his  great  involuntary  tendency  to  exaggerate  everything. 


NERVOUS  AND  PSYCHIC  MANIFESTATIONS.  179 

The  hysteric  may  manifest  other  disturbances  in  connection  with 
sleep  than  those  which  bear  upon  insomnia.  Narcolepsy  consists  of 
sleep  attacks  which  come  on  suddenly  and  wholly  out  of  season,  and 
only  last  for  a  short  time,  perhaps  from  ten  minutes  to  half  an  hour. 
The  frequency  with  which  they  occur  may  vary  from  several  times  a 
day  to  once  a  month.  The  waking  from  these  is  apt  to  be  slow  and 
more  or  less  difficult.  Nothing  differentiates  the  narcoleptic  condition 
from  the  condition  of  sleep.  Its  pathogeny  is  very  difficult  to  under- 
stand. The  most  characteristic  thing  in  this  state  is  the  sudden  loss  of 
consciousness, — its  paralysis,  as  it  were.  The  function  of  conscious- 
ness is  suddenly  arrested,  just  as  the  motor  function  is  abruptly  in- 
hibited in  the  production  of  an  hysterical  paralysis.  Without  insisting 
too  strongly  upon  this,  we  think  it  very  possible  that  the  phenomena 
may  result  from  identically  the  same  mechanism,  and  that  inhibition 
of  consciousness  in  the  hysteric  may  be  brought  about  in  the  same  way 
as  motor  inhibition. 

Lethargy  is  another  hysterical  manifestation  affecting  the  function 
of  sleep.  Sometimes  suddenly,  and  sometimes  after  a  premonitory  aura, 
a  person  is  abruptly  overcome  by  sleep.  Once  fallen  asleep  the  patient's 
face  may  be  pale  or  retain  its  color,  the  muscles,  particularly  the  mas- 
seters,  are  contracted,  the  eyes  are  fixed,  and  disclosed  by  the  eyelids 
which  flutter  rapidly.  Respiration  is  calm,  superficial,  sometimes  slower, 
sometimes  more  rapid,  and  sometimes  panting,  or,  as  in  a  case  of 
Achard's,  of  the  Cheyne-Stokes  type.  The  pulse  is  regular.  The 
temperature  remains  about  normal.  There  may  be  present  generalized 
psychosensory  anaesthesia;  nevertheless,  and  this  is  the  important  thing, 
there  is  no  loss  of  perception.  There  are  subjects  who  in  a  lethargic 
state  are  conscious  of  everything  that  goes  on  around  them. 

Certain  of  these  sleeping  attacks  are  sudden  and  short,  pseudo- 
syncopal.  Others  are  prolonged  for  weeks  and  months.  There  are  cases 
where  lethargic  sleep  has  lasted  for  years.  Generally  they  are  brought 
to  an  end  by  a  convulsive  attack  or  by  passing  over  into  some  other 
hysterical  symptom. 

These  conditions — which,  moreover,  are  very  closely  allied  to  hys- 
terical crises — are  of  very  great  theoretical  importance,  for,  as  a  matter 
of  fact,  the  majority  of  instances  which  have  been  found  of  people  who 
were  buried  alive  must  be  attributed  to  lethargy.  Now,  the  most  ardent 
partisans  of  the  purely  suggestive  nature  of  hysteria  would  undoubtedly 
find  that  it  is  going  a  little  too  far  to  admit  that  a  subject  would  push 
suggestion  so  far  as  consciously  to  allow  himself  to  be  buried.  One 
might  offer  as  an  explanation  the  possibility  of  errors  in  retrospective 
diagnosis.  One  will  say  that  the  real  hysterics  have  always  managed 
to  arrange  it  so  as  to  wake  up  in  time.  Nevertheless,  there  are  some 
who  have  pushed  the  joke  pretty  far,  even  up  to  the  point  of  interment. 
Among  those  who  have  wakened  in  time,  there  are  some  who  were  in 
their  coffins  and  already  under  the  earth. 


180  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

However  this  may  be,  the  psychopathology  of  these  conditions  is 
variable.  Sometimes  it  is  no  more  than  a  prolonged  narcolepsy,  with 
absolute  loss  of  voluntary  or  involuntary  consciousness.  Sometimes  it  is 
voluntary  consciousness  only  that  is  inhibited.  The  psychological 
automatism  remains  intact  and  introduces  passively  in  the  field  of  con- 
sciousness a  great  number  of  images,  of  which  the  subject  is  aware 
as  in  a  dream.    Voluntary  reaction  alone  then  is  absolutely  wanting. 

If  such  facts  are  interesting  because  they  permit  us  in  a  certain 
degree  to  make  landmarks  of  successive  psychological  functions,  they 
are  still  more  important  from  the  same  point  of  view  not  as  disturbances, 
but  as  the  peculiar  conditions  which  hysterics  may  present  in  the 
course  of  sleep.  Hypnotic  sleep  and  somnambulism,  which  is  quite 
closely  allied  to  it,  are  not,  properly  speaking,  pathological  phenomena  ; 
they  are  peculiar  psychological  conditions. 

B.  Headache. — ^Headache  is  a  symptom  so  often  observed  in  the 
course  of  the  psychoneuroses  that  it  deserves  to  be  studied  alone. 

It  is  met  with  so  frequently  in  neurasthenic  states  that,  according 
to  Charcot,  it  formed  one  of  the  primary  symptoms.  Nevertheless,  the 
very  peculiar  headache  which  Charcot  described  under  the  name  of 
*' helmet  headache,"  consisting  of  a  feeling  of  pressure  localized  prin- 
cipally at  the  back  of  the  head  and  the  nape  of  the  neck,  does  not  by  any 
means  seem  to  us  to  be  the  only  form  under  which  the  symptom  is 
manifested. 

Patients  who  are  *'well  read"  are  very  apt  to  use  the  term  *' helmet" 
to  describe  their  pain.  Others,  and  even  a  great  number  of  those  who 
are  well  informed  concerning  their  malady,  use  particular  epithets  to 
describe  their  headache  and  its  very  variable  localizations.  A  band 
around  the  forehead,  sensations  of  emptiness,  throbbings  of  pain  which 
every  movement  exaggerates,  feelings  of  heaviness,  an  undefined  torture 
which  they  cannot  exactly  localize,  are  the  symptoms  of  which  our  sub- 
jects have  most  often  complained. 

They  say  to  us,  *'It  seems  to  me  as  if  I  had  a  weight  of  several 
hundred  pounds  upon  my  head,"  *'I  feel  as  though  my  head  were  held 
in  a  vice,"  "My  brains  actually  beat  in  my  head,"  etc.  Other  patients 
complain  of  sudden  sensations  of  heat  ;  they  feel  as  though  their  '  '  head 
were  on  fire."    Others  complain  of  sharp  or  shooting  pains. 

But  what  we  have  met  most  frequently  is  perhaps  less  a  real  pain 
than  a  distressing  sensation  of  discomfort,  or  emptiness,  or  sometimes, 
on  the  other  hand,  a  tension  or  the  feeling  that  one's  mind  would  not 
work,  sometimes  accompanied  and  sometimes  not  by  feelings  of  dizziness. 
]\Iany  patients  compare  these  sensations  to  those  which  they  have  had 
normally  after  having  pushed  some  intellectual  work,  and  very  naturally 
they  attribute  what  they  feel  to  symptoms  of  exhaustion. 

What  interpretation  could  one  give  to  these  various  forms  of  head- 
ache? It  seems  to  us  that  this  manifestation  has  extremely  diverse 
origins.    First  of  all,  there  appears  to  be  no  doubt  that  in  a  large  number 


NERVOUS  AND  PSYCHIC  MANIFESTATIONS.  181 

of  cases  the  headache  may  be  a  purely  subjective  symptom.  It  is  a 
form  of  localized  pain.  Patients  who  are  struck  by  their  lack  of  brain 
activity  or  the  difficulty  they  have  in  working  are  apt  to  refer  the 
impressions  they  feel  to  the  periphery.  Their  headache  is  only  a  sub- 
jective excuse  for  the  deficiencies  of  which  they  complain. 

Under  other  circumstances,  the  headache  is  subjectively  encouraged, 
and  continued,  so  to  speak.  It  has  really  existed,  but  in  a  transitory 
fashion.  Afterward  it  persists  as  a  state  of  memory  which  is  more  or 
less  continually  evoked.  The  patient's  pain  is  really  only  a  reminiscence. 

Sometimes  the  headache  is  explained  by  the  extreme  malnutrition 
of  the  patient  ;  it  then  belongs  to  the  same  mechanisms  as  those  by 
which  we  explained  the  headaches  of  anaemics  and  certain  convalescents. 

Finally,  and  this  probably  rather  frequently  occurs,  the  headache 
may  be  the  expression  of  a  real  cerebral  exhaustion.  As  a  matter  of 
fact,  although  the  intellectual  work  of  the  neurasthenic  may  have  no 
objective  realization,  the  pain  may  be  none  the  less  real  for  that,  and 
the  constant  absorption  with  preoccupation,  obsessions,  and  emotional 
conditions  and  being  always  exploring  one's  mental  recesses  is  at  least 
as  fatiguing  as  the  most  abstruse  geometrical  problems  or  the  most  subtle 
metaphysical  meditations.  It  is  from  this  mechanism  in  particular  that 
there  seems  to  us  to  proceed  those  diffused  feelings  of  headache  with  vague 
feelings  in  the  head  from  which  so  many  people  suffer.  One  does  not 
have  to  push  the  analysis  very  far  to  find  out  that  these  are  people  who 
are  preoccupied  and  obsessed,  and  that  their  preoccupations  and  obsessions 
allow  them  very  little  rest. 

Insomnia  may  also  play  its  part,  and  help  to  determine  what  is 
described  to  us  as  that  sort  of  continual  feeling  of  soreness  of  the 
head  or  scalp  which  is  the  despair  of  so  many  patients. 

A  transference  to  the  periphery  of  a  sense  of  intellectual  weakness, 
a  reminiscence  which  is  obsessive  or  caused  by  real  fatigue — ^these  are 
in  fact  the  various  mechanisms  which  seem  to  us  able  to  interpret  all 
kinds  of  headaches  in  neurasthenics. 

In  hysterics  one  may  meet  with  nearly  all  the  symptoms  which  we 
have  just  described.  But  in  these  last  patients  the  rôle  of  auto-suggestion 
or  of  hetero-suggestion  is  predominant,  above  all  when  their  troubles 
are  associated  with  phenomena  of  contracture  or  paralysis. 

These  are  often  patients  in  whom  one  has  tried  to  discover  a  possible 
organic  origin  of  their  symptoms,  and  who  have  become  gradually  con- 
vinced of  the  existence  of  the  headache  which  has  been  previously 
sought  for.  The  hysterical  nail,  which  consists  of  an  extremely  sharp 
pain  in  a  very  limited  area  on  top  of  the  head,  has  often  no  other 
origin. 

In  fact,  in  these  patients  painful  subjective  disturbances  are  fre- 
quently accompanied  by  localized  or  diffuse  hyperaesthesia  of  the  scalp. 

C.  Disturbances  of  the  Reflexes. — These  troubles,  which  are  of 
very  slight  importance  from  the  clinical  point  of  view,  involve,  on  the 


182  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

other  hand,  from  the  theoretical  point  of  view,  a  whole  series  of  im- 
portant questions.  We  are  far  from  solving  the  problems  which  are 
offered  by  the  modifications  of  the  reflexes,  and  we  by  no  means  pretend 
that  we  can  offer  here  any  definite  interpretation  of  the  facts  which 
clinical  observation  has  enabled  us  to  establish. 

We  shall  take  up  successively  the  tendon  and  skin  reflexes  in  the 
course  of  neurasthenic  and  hysteric  conditions. 

The  tendon  reflexes  in  neurasthenic  conditions  are  very  frequently 
modified.  The  knee-jerk  may  be  found  perhaps  somewhat  exaggerated 
or  somewhat  diminished  in  such  patients.  But  exaggeration  is  a 
phenomenon  much  more  frequently  observed. 

We  feel  it  necessary  to  point  out  a  certain  number  of  distinctions. 
It  may  happen  that  one  has  to  do  with  patients  who  are  extremely  run 
down  and  emaciated,  in  whom  the  reflexes  act  as  they  do  in  all  con- 
ditions of  grave  dénutrition.  One  knows  that  in  these  conditions 
there  is  sometimes  exaggeration  and  sometimes  diminution  of  the  re- 
flexes, and  that  this  is  the  first  mechanism  of  change  in  the  reflexes 
during  the  course  of  neurasthenia. 

On  the  other  hand,  we  know  that  the  reflexes  vary  according  to 
individuals.  Cases  have  been  shown  where  there  is  congenital  absence 
or  at  least  diminution  of  the  knee-jerk.  We  even  know  subjects  who 
in  their  normal  state  have  very  strong  reflexes.  In  the  absence  of  any 
idea  concerning  the  previous  condition  of  the  reflexes,  it  becomes  very 
difiicult  to  say  whether  the  exaggeration  or  diminution  which  one  has 
discovered  has  or  has  not  anything  to  do  with  the  actual  symptomatic 
expression. 

Under  other  circumstances  we  may  find  ourselves  in  the  presence 
of  morbid  associations.  A  subject  may  be  tuberculous,  or  diabetic, 
and  also  neurasthenic,  and  under  these  conditions  the  disturbances 
of  the  reflexes  may  be  attributed  to  the  associated  disease  rather  than  to 
the  psychoneurosis  itself. 

Finally,  there  does  not  seem  to  us  to  be  any  question  that  the  exag- 
geration of  reflexes  in  particular  may  be  in  a  great  many  cases  con- 
sidered as  a  symptom  peculiar  to  the  neurasthenic  condition.  But 
how  shall  we  interpret  this  phenomenon? 

First  of  all,  clinical  observation  has  shown  us  that  these  exaggera- 
tions of  the  reflexes  are  found  particularly  marked  in  all  the  cases  in 
which  the  patients  are  in  an  extremely  emotional  state.  By  repeated 
examinations  we  have  even  assured  ourselves  that  this  exaggeration 
would  to  some  degree  vary  with  the  emotional  condition  itself,  more 
particularly  when  our  subjects  would  say  of  themselves  that  they  felt 
**more  nervous,^'  and  less  markedly  so  when,  on  the  contrary,  from  the 
mental  or  moral  point  of  view,  they  felt  themselves  calm  and  tranquil. 
So  much  so  that  from  the  start  one  can  be  sure  that  these  changes  in 
the  reflexes  have  no  relation  to  any  organic  disturbance  or  any 
modification  of  nutrition. 


\ 


NERVOUS  AND  PSYCHIC  MANIFESTATIONS.  183 

The  interpretation  which  it  seems  to  us  should  be  adopted  is  as 
follows:  The  various  functions  which  devolve  upon  the  cerebro-spinal 
axis  cannot  be  isolated  from  the  anatomical  point  of  view  any  more 
than  from  the  physiological.  There  is  reciprocal  action  of  the  phenom- 
ena of  the  automatic  life  on  those  of  the  conscious  life,  and  vice  versa. 
In  the  same  way  that  a  given  idea  is  able  to  provoke  vasomotor  and 
secretory  actions,  etc.,  so  a  given  mental  condition  is  capable  of  modify- 
ing a  whole  set  of  reflex  phenomena.  Concentration  of  consciousness 
(obsessions)  ^ or  diffusion  of  consciousness  (emotions)  may  in  this  way 
act  upon  and  disturb  the  inhibition  or  the  tonus  'which  the  different 
stages  of  nervous  functions  receive  one  from  the  other.  Such  is  the 
hypothetical  explanation  which  an  examination  of  the  facts  suggests. 

Among  hysterics,  excluding  accidents,  one  may  see  various  conditions 
of  the  reflexes.  But  the  interesting  problem  is  raised  by  modifications 
which  the  reflexes  may  undergo  in  the  course  of  hysterical  symptoms, 
and  particularly  in  the  case  of  paralyses.  One  may  note  in  hysterical 
paralyses  a  more  or  less  considerable  exaggeration  of  the  tendon  reflexes. 
May  this  exaggeration  of  reflectivity  go  so  far  as  to  produce,  as  in 
organic  paralyses,  ankle-clonus?  As  a  matter  of  fact,  one  of  us  has 
been  able  to  observe,  without  any  organic  association  and  without  the 
slightest  possibility  of  any  simulation,  actual  cases  where  this  phenom- 
enon was  produced  in  hysterics;  but  it  is  something  which  happens 
very  rarely.  Hysteria,  either  directly  or  indirectly,  would  thus  be  capable 
of  setting  the  spinal  automatism  at  liberty. 

Cutaneous  reflexes  may  also  be  modified  in  the  course  of  a  psycho- 
neurosis. 

Ordinarily,  in  neurasthenia  the  modifications  that  these  reflexes 
undergo  are  very  slight,  and  depend  upon  the  condition  of  general 
reflectivity.  When  the  tendon  reflexes  are  strong,  it  is  rare  that  the 
cutaneous  reflexes  are  not  also  accentuated,  and,  inversely,  any  diminu- 
tion is  apt  to  be  found  in  the  tendon  reflexes  as  well  as  in  the  skin  or 
mucous-membrane  reflexes. 

Nevertheless,  there  is  no  absolute  law,  and  it  has  seemed  to  us  that 
in  the  zone  of  localization  of  their  functional  manifestations  neuras- 
thenics may  present  remarkable  exaggerations  of  the  cutaneous  reflexes. 
Peculiar  irritability  of  the  abdominal  wall  in  gastro-intestinal  fixations, 
exaggeration  of  the  pharyngeal  reflex,  fixations  in  the  regions  of  the 
upper  digestive  tracts — such  facts  we  have  been  able  to  demonstrate 
on  several  trials. 

In  hysteria,  in  the  course  of  paralyses  or  hemianaesthesiae  we  have 
been  able  to  establish  unquestionably  disappearance  of  the  cremasteric 
reflex  in  a  certain  number  of  cases.  As  for  the  plantar  cutaneous  reflex, 
we  have  never  found  dorsal  extension  of  the  great  toe  (Babinski's  sign). 
On  the  contrary,  we  believe  that  the  cutaneous  plantar  reflex,  as  well 
as  that  of  the  tensor  of  the  fascia  lata,  may  be  absent  in  these  patients 
on  the  hemianaesthetic  side.    One  of  us  has  observed  three  exaniples  in 


184  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

his  service  during  the  last  year.  In  these  three  patients,  afflicted  with 
absolute  hemiansesthesia,  two  women  and  a  man,  the  sole  of  the  foot 
did  not  respond  to  any  stimulus  whatever,  and  the  reflex  of  the  fascia 
lata  was  likewise  lacking.  On  the  well  side  the  reaction  of  the  toes 
and  the  fascia  lata  was  normal.  Two  of  these  patients  were  cured 
of  their  hemi anaesthesia,  and  then  recovered  their  plantar  and  fascia- 
lata  reflexes. 

We  shall  not  dwell  any  longer  upon  this  question  of  reflexes.  The 
only  theoretical  point  which  really  matters  to  us  is  to  know  that  purely 
psychic  influences  are  capable,  to  a  considerable  extent,  of  bringing 
about  modifications  in  phenomena  which  are  habitually  regarded  as 
purely  automatic. 

This,  however,  is  not  at  all  astonishing,  if  one  considers  the  evident 
existence,  as  functional  manifestations  of  psychoneuroses,  of  disturb- 
ances which,  like  spasms  and  contractures,  are  really  only  reflexes 
which  have  become  permanent,  persistent,  or  stereotyped  in  some  way. 

D.  Disturbances  of  Speech. — One  may  sometimes  find  in  the 
hysteric  a  symptomatic  ensemble  which  more  or  less  approaches  motor 
aphasia.  But  writing  is,  as  a  rule,  wholly  unaffected.  When  it  is  a 
question  of  agraphia,  which  rarely  occurs,  it  is  total,  and  exists  for  all 
kinds  of  writing. 

On  the  other  hand,  a  very  few  cases  of  sensory  aphasia  and  of  pure 
verbal  deafness  have  been  noted  in  hysterics. 

A  thing  which  is  much  more  frequent  in  the  hysteric  is  mutism. 
Mutism  strikes  hysterics  at  every  age;  nevertheless,  it  is  rare  after 
forty.  It  may  come  on  after  an  emotional  attack,  and  take  place  sud- 
denly, or,  on  the  other  hand,  progressively,  preceded  by  stuttering^ 
then  by  the  impossibility  of  speaking  aloud  (whispering),  before  it 
becomes  confirmed.  Once  established,  it  makes  the  patient  absolutely 
dumb,  incapable,  in  spite  of  the  integrity  of  his  phonetic  muscle,  to 
utter  the  slightest  sound  or  even  a  cry.  It  is  really  a  purely  motor 
disturbance  related  to  all  the  psychological  functions.  In  some  cases 
mutism  is  not  absolute  :  the  patient  may  make  a  few  sounds  but  cannot 
utter  them  in  a  loud  voice. 

When  once  established,  hysterical  mutism  lasts  sometimes  for  hours 
and  sometimes  for  years. 

It  is  very  evident  that  of  all  hysterical  manifestations  mutism  is 
perhaps  the  one  which  most  easily  permits  simulation.  It  is  none  the 
less  true,  however,  that  we  know  a  certain  number  of  cases  where  the 
possibility  of  this  could  not  for  a  moment  be  considered.  One  of  us 
has  seen  a  case  like  this,  a  teacher  who  was  extremely  devoted  to  her 
pupils  and  in  love  with  her  profession,  who  was  suddenly  struck  mute 
as  the  result  of  a  violent  emotion.  This  patient  was  a  woman  of 
upright  character,  and,  in  spite  of  her  very  strong  desire,  had  been 
mute  for  four  years  when  she  came  into  our  wards.     She  was  only 


NERVOUS  AND  PSYCHIC  MANIFESTATIONS.  185 

cured  after  several  months,  and  then  by  exciting  a  very  strong  emotion 
in  her. 

It  does  not  seem  to  us  that  such  cases  should  be  any  more  difficult 
to  grasp  than  many  other  functional  manifestations.  Does  not  every- 
body know  that  emotion  will  "make  the  voice  break"  and  render  one 
incapable  of  uttering  a  sound?  The  hysteric,  as  we  have  already  seen, 
fixes  himself  in  his  emotional  symptoms.  These  become  crystallized  in 
him,  as  it  were.  When  in  phenomena  of  this  kind  suggestion  comes  in  as 
a  secondary  element,  the  thing  is  very  possible.  Persuaded  of  his  in- 
ability, the  patient  may  continue  his  auto-suggestions,  and  the  symptom 
will  last  as  long  as  the  suggestive  action  persists,  and  will  only  give 
way  to  some  new  emotional  influence  or  an  opposite  suggestion.  But 
the  emotion  will,  nevertheless,  be  always  the  main  agent.  When  it 
comes  to  a  question  of  a  disturbance  of  speech,  the  patients  who  have 
lost  their  voice  by  reason  of  an  emotional  crisis  very  probably  do  not 
know  how  to  recover  it,  because  their  hopelessness  hinders  them  from 
making  any  effort  in  this  direction. 

This  was  particularly  so  in  the  case  of  the  teacher  of  whom  we  have 
just  spoken,  who,  every  time  that  one  tried  to  persuade  her  that  she 
could  speak,  would  reply  in  writing  that  she  was  convinced  that  she 
would  never  be  able  to  speak  again. 

Among  neurasthenics  one  sees  other  disturbances  of  speech,  which, 
the  patients  express  by  saying,  "I  can  no  longer  find  the  words  I  want 
to  use,"  "I  can  hardly  understand  what  people  say  to  me."  "I  da 
not  understand  what  I  read.  '  '  In  reality  these  disturbances  correspond 
to  two  kinds  of  phenomena.  There  is,  on  the  one  hand,  a  purely 
ideational  disturbance,  which  we  shall  take  up  again  when  we  study 
the  affections  of  psychological  functions;  and  there  are,  on  the  other 
hand,  phobic  manifestations,  which  we  shall  consider  with  all  the 
disturbances  of  this  kind  which  affect  the  nervous  system. 

E.  Acquired  Disturbances  of  Psychological  Functions. — The  dis- 
turbances of  psychological  functions  which  one  may  come  across  in  the 
course  of  the  psychoneuroses  are  extremely  varied. 

We  may,  from  the  start,  divide  them  into  antecedent  disturbances 
and  consecutive  disturbances.  We  place  under  the  term  antecedent  dis- 
turbances those  which,  whether  constitutional  or  acquired,  were  present 
before  the  development  of  the  psychoneurosis  with  its  symptoms.  We 
shall  take  up  their  study  in  the  second  part  of  this  work.  The  con- 
secutive disturbances,  which  are  the  only  kind  we  shall  consider  here, 
are  developed  secondarily,  and  give  rise  to  a  whole  series  of  manifesta- 
tions which  did  not  form  an  integral  part  of  the  previous  mentality 
of  these  patients. 

Such  a  distinction  may  appear  subtle.  It  is,  however,  a  very  im- 
portant one.  Neurasthenics  may  in  fact  accidentally  present  a  whole 
series  of  psychic  troubles  which  one  would  find  constitutionally  estab- 
lished in  certain  subjects  belonging  to  a  family  whose  mentality  was 


186  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

different.    We  are  alluding  to  the  psychasthenics  of  Janet  in  particular. 

Can  one  say  that  acquired  psychological  troubles  exist  in  the 
hysteric?  If  in  their  case  some  psychic  medium  may  have  been  acci- 
dentally inhibited, — such,  for  example,  as  the  various  forms  of  lan- 
guage, as  is  the  case,  as  we  shall  see  further  on, — then  the  mental  dis- 
turbances in  these  patients  are  essentially  constitutional.  Therefore, 
they  would  not  be  described  here. 

The  same  thing  is  not  at  all  true  of  the  neurasthenic.  In  his  case, 
in  projiortion  as  his  affection  develops  there  appears  a  whole  series  of 
secondary  disturbances,  holding  a  capital  place  in  the  subjective  and 
objective  symptomatology  of  these  patients. 

The  immense  majority  of  neurasthenics  complain  of  not  being  able 
to  fix  their  attention  on  any  intellectual  work  whatsoever,  no  matter 
how  hard  they  try.  All  work,  they  say,  at  the  end  of  a  certain  time, 
which  varies  according  to  the  individual  nature  and  on  different  days, 
fatigues  them.  As  a  rule,  it  will  be  their  necessary  occupations  which 
will  fatigue  them  the  most  and  the  quickest.  More  or  less  rapidly,  they 
will  find  themselves  obliged  to  give  up  either  the  daily  routine  by 
which  they  live  or  the  intellectual  work  which  interests  them. 

Is  it  a  question  here  of  what  might  be  called  an  organic  intellectual 
deficiency,  tending  to  some  particular  form  of  fatigue,  or  an  exhaustion 
which  takes  place  more  rapidly  than  what  might  be  called  the  psychic 
contraction?  Not  at  all,  and  more  often  it  is  the  patient  himself  who 
furnishes  you  the  proof  of  this.  If  certain  subjects  are  sufficiently 
logical  to  attribute  their  rapid  fatiguability  to  all  kinds  of  attention, 
there  are  certain  others  who  forget  themselves.  One  sees  patients  who 
declare  themselves  to  be  exhausted  at  the  end  of  a  few  minutes'  atten- 
tive work,  and  who  devote  hours  to  the  solution  of  problems  in  chess 
or  geometry.  But,  above  all,  the  time  when  logic  is  wholly  lost  from 
sight  is  when  the  patient  finds  himself  with  his  physician.  With  him, 
the  very  individual  who  has  just  said  that  he  was  incapable  of  any 
intellectual  effort  will  be  able  to  bear  up  through  discussions  which 
last  for  hours,  exhausting  the  doctor,  but  from  which  the  patient  sallies 
forth  fresh  and  cheerful,  provided  he  has  found  some  consolation. 

This  intellectual  incapacity  may  be  interpreted  objectively  and  sub- 
jectively. Sometimes  the  patient  is  able  to  fix  his  attention  only  for  a 
short  time,  a  time  during  which  intellectual  activity  is  normal.  It  is 
not  then  a  question  of  rapid  fatigue.  Under  other  circumstances  it 
seems  that  the  elementary  psychological  functions  may  be  the  ones 
which  are  troubled.  The  patient  is  quite  capable  of  fixing  his  atten- 
tion for  a  time,  often  fairly  long,  but  the  work  that  he  would  have 
accomplished  formerly  in  a  few  minutes  will  take  him  hours.  Simple 
operations,  mental  calculations,  will  seem  very  difficult  to  him.  Nearly 
always,  however,  not  to  say  always,  the  work  or  the  calculation  will 
be  right.     That  is  to  say,  in  other  words,  the  elementary  psychological 


NERVOUS  AND  PSYCHIC  MANIFESTATIONS.  187 

phenomena  remain  qualitatively  unharmed,  and  what  is  affected  is  the 
faculty  of  association. 

Other  patients  complain  of  distractions,  involuntary  flights  of  mind. 
"They  are  not  there,"  they  say,  but  when  they  are  ''there,"  the  work 
is  accomplished  in  a  normal  manner  both  as  to  quality  and  quantity. 
Others  again  say  that  their  memory  is  affected,  particularly  for  what 
concerns  recent  events.  ''I  am  obliged  to  make  a  note  of  everything," 
they  say,  ''because  if  I  did  not  I  never  would  remember  anj^thing." 

Certain  others  do  not  complain  of  their  memory,  properly  speaking. 
They  can  remember  things,  but  their  power  of  recall  is  slower  than 
usual;  whence  arises  a  series  of  secondary  disturbances  in  the  imagina- 
tion and  in  ideation. 

There  are  subjects  who,  on  the  other  hand,  suffer  from  recall,  from 
memories  too  numerous  and  diffuse  which  present  themselves  to  con- 
sciousness. Ideation  is  affected  because  in  the  multitude  of  phenom- 
ena of  consciousness  the  patient  can  no  longer  choose;  he  therefore 
becomes  a  sort  of  psychological  automaton;  he  sees,  he  says,  "as  if 
he  were  in  a  dream,"  and  he  feels  incapable  in  various  degrees  of 
any  cerebral  control,  or  of  forming  any  judgment.  All  the  phenomena 
of  life  appear  to  him  as  on  the  same  plane.  He  is  like  a  person  in  the 
theatre  who  cannot  distinguish  between  the  actors  and  the  "supers." 
He  has  in  some  way  lost  his  sense  of  proportion.  He  will  magnify  some 
trifling  detail  to  such  a  degree  that  the  important  facts  lose  their  relief. 
Thus,  one  will  often  see  a  patient  whom  an  insignificant  thing  will 
preoccupy  just  as  much  as  an  important  thing.  It  would  not  be  exact 
to  say  that  he  wholly  neglects  the  latter.  It  often  only  appears  to  be 
so  on  account  of  the  relation  between  the  mentality  of  the  observer 
and  the  real  mentality  of  the  patient.  The  physician,  conscious  of  his 
own  mentality,  sees  this  lack  of  proportion,  and  is  inclined  to  accuse  the 
patient  of  taking  no  interest  in  the  most  important  things  of  his  life. 
This  is  not  exactly  true.  He  does  not  lack  interest,  but,  rather,  he  is 
interested  in  too  many  things,  a  number  of  which  are  futile. 

These  reactions  of  failing  interest  may  occur  at  any  time,  but  it  is 
when  any  new  psychological  phenomenon  has  appeared  that  it  is  neces- 
sary to  know  whether  any  systematization  has  taken  possession  of  the 
patient. 

These  systematizations  are  phobias  and  obsessions.  It  would  be  a 
mistake  to  believe  that  manifestations  of  this  kind  do  not  belong  to 
neurasthenia,  and,  on  this  account,  to  classify  such  patients  in  another 
pathological  group,  as  psychasthenics.  We  should  be  tempted,  on  the 
other  hand,  to  say  that  it  is  a  characteristic  of  the  neurasthenic  to  have 
obsessions  and  to  be  liable  to  them.  This  is  easy  to  conceive;  for 
is  an  obsession  anything  else  than  an  involuntary  and  irresistible  ap- 
parition in  the  field  of  consciousness,  phenomena  of  psychological 
automatism?  Any  individual  who  is  not  "master  of  himself"  is  prac- 
tically phobic  or  obsessed.     The  neurasthenic,   having  no  longer  his 


188  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

cerebral  control, — ^that  is,  his  judgment, — ^has  accidentally  lost  the 
mastery  over  himself,  which  the  psychasthenic  has  never  had  except  in 
the  most  relative  degree. 

Still  further,  while  the  psychasthenic  recognizes  his  obsessions,  and 
while  he  is  vainly  trying  to  drive  them  away,  the  neurasthenic  is  com- 
placent about  them.  Here  we  enter  into  phenomena  of  another  kind. 
It  is  here  that  along  with  obsessions  are  found  what  are  called  pre- 
occupations, having  a  very  different  psychological  mechanism.  These 
are,  if  you  will,  voluntary  obsessions,  depending  directly  on  the  moral 
condition  of  the  patients.  In  neurasthenics  pessimism  is  evidently  at 
the  bottom  of  this  condition.  They  also  entertain  voluntarily  all  the 
depressing  ideas,  all  the  hypochondriac  preoccupations  that  the  psycho- 
logical automatism  may  have  introduced  into  the  field  of  their  con- 
sciousness either  as  an  incident  or  as  an  obsession.  Here  we  must  take 
into  consideration  the  fact  that  the  passing  moral  condition  either  in- 
hibits or  excites — it  comes  to  the  same  thing — psychological  automatism. 
If  we  are  gay  or  sad,  our  automatism  will  not  introduce  into  our  field 
of  consciousness — or  our  field  of  consciousness  will  not  permit  the 
entrance  of — any  ideas  but  those  which  are  gay  or  sad.  More  or  less 
influenced  by  his  condition  and  more  or  less  weak,  the  neurasthenic  will, 
therefore,  have  hardly  any  but  pessimistic  ideas,  which  will  crystallize 
in  some  way  into  a  state  of  preoccupation  or  obsession. 

An  example  will  help  to  make  our  thought  clear:  We  see  a  fire- 
arm, a  revolver  or  a  rifle,  or  perhaps  a  sword  or  a  knife.  Among  the 
many  ideas  which  might  be  associated  with  these  things  there  are  some 
which  are  pessimistic,  like  those  of  suicide  or  the  possibility  of  a 
criminal  action.  A  healthy  person  will  pay  no  attention  to  these  ideas. 
A  neurasthenic,  on  the  other  hand,  by  reason  of  his  moral  condition, 
will  lay  hold  of  the  idea  and  cling  to  it.  He  will  think  that  he  might 
be  *' tempted"  to  commit  suicide,  that  he  might  *' conceive  the  idea'' 
of  injuring  some  one.  This  idea  disturbs  him,  and  remains  persistently 
in  his  mind.  He  will  think  of  it  for  a  long  time.  He  is  henceforth 
caught  in  a  vicious  circle.  In  fact,  the  more  he  thinks  about  it  the 
more  there  will  be  registered  in  his  psychological  automatism  many 
vivid  impressions,  which,  as  a  result,  will  have  all  the  greater  oppor- 
tunity of  running  through  his  field  of  consciousness  again  and  again, 
and  all  the  more  so  because  at  the  same  time,  by  the  simple  fact  of 
circumstances,  associations  of  ideas,  which  are  capable  of  recalling  them 
are  multiplying  qualitatively,  so  to  speak.  Thus,  step  by  step,  the 
neurasthenic,  who  has  at  first  been  merely  preoccupied,  becomes  finally, 
by  the  very  reason  of  this  common  intellectual  mechanism,  the  subject 
of  obsessions.  A  voluntary  obsession,  if  one  might  so  call  it,  directly 
creates  an  involuntary  obsession,  or  a  true  obsession.  But  the  latter, 
and  this  is  the  important  point  of  diagnosis,  is  secondary. 

We  shall  not  dwell  upon  this  just  now,  but  we  have  already  seen 


NERVOUS  AND  PSYCHIC  MANIFESTATIONS.  189 

that  this  is  the  key-stone  to  the  whole  construction  of  visceral  symptoms 
in  neurasthenics. 

However  it  may  be,  when  the  neurasthenic  has  gotten  an  obsession 
it  goes  without  saying  that  his  mental  incapacities  are  multiplied  and 
aggravated,  because  by  one  road  or  another  he  can  always  return  to 
his  obsession.  Obsessions  may  take  a  variety  of  forms,  but  it  is  especially 
hypochondriacal  obsessions  which  are  met  in  these  patients.  The  phobia 
of  suicide,  the  phobia  of  harming  some  one  else,  and  other  such  scrupu- 
lous obsessions  are  also  found,  but  much  less  frequently. 

As  to  the  mechanism  which  produces  the  mental  disturbances  on 
which  these  accidents  are  grafted,  it  depends  altogether  upon  the 
emotional  state  in  which  the  neurasthenic  is  indulging,  or  in  which  he 
finds  himself.  We  shall  take  up  this  question  further  along.  But  it  is  evi- 
dent that  the  succession  of  emotions,  intellectual  disturbances,  preoccupa- 
tions, and  obsessions  which  we  have  established  do  not  appear  in  regular 
succession,  so  that  one  would  be  able  to  say  that  there  were  three  cor- 
responding neurasthenic  periods  developing  as  time  goes  on. 

In  reality,  and  almost  from  the  start,  the  phenomena  are  complex. 
On  examining  patients,  one  finds  that  obsessions  or  preoccupations  and 
intellectual  disturbances  are,  as  a  matter  of  fact,  reciprocally  con- 
ditioned one  by  the  other.  At  this  period,  if  one  did  not  take  into 
consideration  the  way  in  which  the  symptoms  started,  it  would  seem  as 
if  all  intellectual  disturbances  were  directly  caused  by  preoccupations 
or  obsessions. 

In  fact,  if  in  those  patients  w^ho  complain  of  intellectual  disturbances 
of  every  kind  one  pushes  the  analysis  a  little  further,  one  will  readily 
perceive  that  all  these  disturbances,  or  at  least  the  majority  of  them, 
are  due  to  diffusion  of  the  attention  toward  the  obsessions  or  preoccu- 
pations. 

Of  a  patient  who  complains  of  tiring  rapidly  during  any  intellectual 
work,  of  being  distracted,  or  of  finding  it  impossible  to  fix  his  attention, 
ask,  ''What  do  you  think  about  when  you  are  working?"  He  will  in- 
variably reply,  '  '  I  think  of  my  illness,  or  of  such  and  such  a  vicissitude 
that  it  has  brought  about,"  and,  if  your  patient  reads  without  under- 
standing what  he  reads,  if  he  lingers  a  long  time  over  some  work  which 
does  not  advance,  if  he  experiences  difficulties  in  formulating  his  ideas, 
it  is  not  because  he  is  incapable  of  working  or  of  thinking,  but  it  is 
because  he  is  thinking  of  something  else,  something  which  is  particu- 
larly dear  to  him,  that  is  his  ill  health. 

There  are  some  patients  who  manage  to  get  hold  of  themselves,  but, 
in  order  to  become  absorbed  in  their  occupation,  they  are  obliged  to  do 
double  work, — the  labor  of  fixing  their  attention  upon  the  undertaking 
in  hand,  and  the  labor  of  struggling  against  distraction  caused  by  the 
obsession  or  the  preoccupation  which  is  always  flooding  their  conscious 
mentality.  They  thus  plunge  into  heroic  struggles  which  cannot  help 
but  produce  fatigue  which  this  time  is  real.    Here  again  is  one  of  these 


190  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

troubles  belonging  to  the  mechanism  of  disharmony,  like  so  many 
others  which  we  have  already  met. 

Under  other  circumstances,  and  among  those  whom  we  have  already 
described  as  ''neurasthenics  who  have  arrived,"  the  intellectual  fatigue 
is  real,  and  in  direct  proportion  to  the  emaciation  and  weakness  of  the 
subject,  who  may  at  the  same  time  be  physically  as  well  as  morally 
depressed.  In  these  patients  a  very  curious  phenomenon  sometimes 
occurs  which  resembles  a  periodic  psychosis.  It  is  not  at  all  rare, 
among  such  subjects,  to  find  that  for  short  periods  of  time  intellectual 
work  becomes  almost  too  easy  for  them.  This  is  because  a  new  element 
has  come  into  play, — namely,  the  psychic  excitement  which  may  be  met 
with  in  all  conditions  of  psychic  depression.  This  is  a  phenomenon 
of  organic  nature,  but  secondary.  It  is  of  great  practical  interest  to 
recognize  it,  because,  if  the  patient  makes  use  of  his  excitement  and 
profits  by  it  to  do  any  rather  arduous  work,  he  becomes  rapidly  ex- 
hausted for  often  a  considerable  time. 

All  these  psychological  troubles  are  apt  to  be  followed  by  rather 
peculiar  sensations,  due  to  the  fact  that,  under  the  influence  of  the 
very  considerable — though  wholly  abnormal — development  of  their  inner 
life,  these  patients  lose,  so  to  speak,  contact  with  the  outer  world,  and, 
their  consciousness  being  incumbered  by  former  incidents  and  every 
kind  of  preoccupation,  they  get  to  the  point  where  sensory  stimuli 
produce  nothing  but  diffused  or  remote  images:  they  listen  without 
hearing;  they  look  without  seeing.  In  a  word,  they  are  ''somewhere 
else."  When  by  chance,  or  because  it  is  keener  than  usual,  a  sensory 
stimulus  mounts  into  conscious  perception,  it  surprises  the  patient.  It 
wakes  him  up,  so  to  speak,  but  before  he  completely  resumes  his  relations 
with  the  external  world  more  or  less  time  has  been  lost.  With  the 
patient  who  is  absorbed  in  his  reflections  all  communications  with  the 
outer  world  have  been,  as  it  were,  cut  off.  The  stimulus  which  he  has 
perceived  has  reestablished  one  of  them,  but  it  takes  a  moment's  time 
before  he  can  make  connection  with  all  the  others,  and  these  are  the 
subjective  impressions  felt  during  this  period  of  getting  hold  of  one's 
self  which  patients  express  by  saying  that  they  have  what  they  de- 
scribe as  "empty  brains,"  or  again  when  they  complain  of  sensations 
of  dizziness. 

In  a  normal  condition  all  our  functions  of  relation  and  balance  in 
our  environment  are  assured  by  sensory  stimuli  which  are  more  or  less 
consciously  perceived,  so  that  the  outer  world  is  continually  projected 
upon  our  minds.  The  neurasthenic  finds  himself  in  exactly  the  situa- 
tion of  a  healthy  individual  who  is  suddenly  wakened  from  a  sound 
sleep.  The  latter,  before  coming  to  himself  and  being  aware  of  exactly 
what  has  happened  to  him,  and  of  his  surroundings,  will,  in  the  same 
way,  lose  a  moment's  time,  in  the  course  of  which  he  will  force  himself 
to  connect  his  actual  impressions  with  the  previous  sensations  whose 
continuity  sleep  has  interrupted.     He  will  feel  exactly  as  the  neuras- 


NERVOUS  AND  PSYCHIC  MANIFESTATIONS.  191 

thenic  does,  that  his  ''brain  is  empty."  He  will  be  under  the  im- 
pression that  he  cannot  walk  straight.  As  a  matter  of  fact,  he  may 
even  start  off  in  the  wrong  direction,  stumble  over  obstacles,  etc. 

Such,  then,  is  the  origin  of  these  sensations  of  emptiness  in  the  brain, 
and  impressions  of  dizziness,  which  make  such  an  unfortunate  im- 
pression upon  patients,  who  may  manufacture  from  them  a  whole 
series  of  secondary  phenomena,  such  as  we  shall  see  in  a  moment.  In 
reality  the  sensations  of  cerebral  emptiness,  expressing  in  the  psychic 
domain  the  same  facts  as  vertigoes  in  the  physical  domain,  may  be 
included  in  one  and  the  same  definition:  they  are  phenomena  of  awak- 
ening and  of  regaining  consciousness  of  the  external  world. 

The  disturbances  of  will  and  character  which  we  meet  in  neuras- 
thenics seem  to  us  to  be  directly  dependent  upon  their  mental  state. 

According  to  writers  on  the  subject,  it  would  seem  as  though  abulia 
constituted  a  most  important  psychological  symptom  of  neurasthenia. 
This  is  a  great  error,  coupled  with  profound  injustice.  When  they 
bring  such  a  judgment  to  bear  upon  the  patients,  they  confuse  two 
essentially  different  things.  The  will  does  not  act  in  a  void  or  in  space  ; 
and  there  are,  as  a  matter  of  fact,  two  kinds  of  will, — the  will  of  itself, 
a  psychological  faculty  which  supposes  in  the  patient  the  disposition 
of  a  quantity  of  given  energy,  and  the  practical  will  which  consists  in 
making  this  energy  move  along  certain  definite  paths.  The  neuras- 
thenic very  often  possesses  a  storehouse  of  energy  which  he,  moreover, 
expends,  but  expends  unwisely  and  unprofitably,  without  any  practical 
result.  He  makes  a  brave  struggle,  but  for  nothing.  His  will  is  there, 
but  it  has  nothing  to  rest  on  ;  what  it  accomplishes  is  of  no  value. 

In  other  words,  he  always  is  in  possession  of  this  instrument,  but  he 
does  not  know  how  to  use  it,  because,  in  the  very  nature  of  things,  on 
account  of  the  intellectual  and  moral  difficulties  in  which  he  finds  him- 
self, his  activity — the  practical  expression  of  use  of  the  will — becomes 
unequal  to  his  demands.  We  say  of  a  healthy  man  that  he  has  a 
''strong  will"  when  we  see  him  using  any  considerable  amount  of 
energy  in  attaining  some  determined  end,  and  when  he  concentrates  all 
his  activity  along  the  line  which  he  has  laid  out  for  himself.  There 
can  be  no  will  where  there  is  no  rational  systematization.  It  is  this 
rational  systematization  of  which  the  neurasthenic  is  incapable  because 
he  has  lost  the  sense  of  proportion. 

Then  other  elements  come  in,  which,  however,  are  secondary  and 
acquired.  The  neurasthenic  may  preserve  what  is  virtually  a  will, 
which  he  no  longer  uses,  because  previous  experiences  or  his  weak  moral 
condition  have  impressed  him  with  his  sense  of  helplessness.  He  has 
reached  the  point  where  he  does  not  make  any  effort,  because  he  is  cer- 
tain beforehand  that  no  result  can  be  obtained.  Now,  as  far  as  the 
practical  will  is  concerned  in  its  application  to  external  things,  one 
can  very  well  see  that  preoccupations  and  obsessions  which  lead  to  a 
life  of  self-absorption  may  peculiarly  inhibit  it.    One  really  cannot  be 


192  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

too  self-absorbed  and  at  the  same  time  pay  proper  attention  to  external 
things.  The  neurasthenic  lives  wholly  in  himself,  and  hardly  permits 
any  interests  concerning  outside  activities  to  cross  the  threshold  of  his 
consciousness. 

All  these  elements  may  be  added  together  and  combined.  They  ex- 
plain the  appearance  of  being  abulic  which  our  patients  acquire.  They 
explain  why  their  wills  are  never  the  same;  why  they  are  variable, 
irregular,  and  essentially  wavering.  They  make  us  see  how  the  neuras- 
thenic susceptible  of  phobic  manifestations  or  obsessions  may  be  in- 
capable of  impulses. 

Just  here  we  ought  to  give  our  attention  for  a  moment  to  a  certain 
small  secondary  point  which,  nevertheless,  is  important.  Hardly  a  day 
passes  but  what  in  the  literature  of  current  events  one  reads  that  Mr. 
or  ]\Irs.  X.  has  committed  suicide  during  an  attack  of  neurasthenia,  or 
has  perpetrated  some  criminal  act.  We  have  seen  that  the  reading  of 
such  facts  provides  a  starting-point  for  preoccupations  and  phobias. 
Now,  a  neurasthenic  never  commits  suicide  and  never  hurts  anybody. 
He  is  wholly  incapable  of  it.  In  his  case  it  is  purely  a  question  of 
stopping  and  drawing  back,  and  if  the  conscious  progression  in  'any 
determined  path  is  extremely  difficult  for  him,  all  the  more  so  is  any 
impulsive  decision  contrary  to  the  very  nature  of  his  condition.  Such 
a  thing  would  be  absolutely  contradictory  to  all  laws. 

All  the  disturbances  of  the  will  in  the  neurasthenic  come  back  to 
this  fact,  that  he  reasons  badly.  It  is  not  that  he  is  lacking  in  reason, 
but  that  he  reasons  too  much,  all  the  time  and  on  every  subject,  and  yet 
is  incapable  of  following  out  a  single  idea  if  he  is  not  helped  toward  it. 

But  let  some  outside  element  come  in,  in  particular  let  something 
really  important  that  would  seriously  move  him  call  him  back  to  his 
normal  life,  or  let  a  psychotherapeutic  influence  make  a  definite  path 
for  his  efforts,  and  immediately  this  man,  whose  will  was  thought  to 
be  so  inefficient,  will  find  himself  capable  of  an  energy  which  certainly 
no  one  ever  suspected  in  him.  To  appreciate  this  fact,  one  has  only  to 
see  what  one  can  get  out  of  the  will  of  such  patients  the  moment  one 
has  gained  their  confidence.  There  is  no  one  who  will  show  more  tenacity 
or  a  firmer  will,  or  more  vigorous  discipline.  The  neurasthenic  is  no 
more  abulic  than  he  is  asthenic  or  exhausted.  If  he  appears  to  be  all 
this  objectively  and  subjectively,  it  is  because  everything  is  retained 
in  his  psychological  and  physical  mechanism,  and  that  he  is  essentially 
lacking  in  coordination,  because  under  the  influence  of  his  moral  con- 
dition the  end  and  aim  of  life  escapes  him.  It  would  seem  that  each  of 
his  psychological  functions  was  evolving  on  its  own  account — only  on 
the  ground  of  pessimism  and  discouragement,  because  here  everything 
falls  into  line — the  instruments  agree  and  harmony  is  established. 

As  to  the  modifications  of  character  which  one  finds  in  neurasthenics, 
they  are  extremely  numerous  according  to  what  people  around  them 
say.    They  are  egoistic,  self-centred,  touchy,  peevish,  complaining,  very 


NEEVOUS  AND  PSYCHIC  ]\iANIFE STATIONS.  193 

irritable,  and  extremely  sensitive,  weeping  at  the  slightest  thing,  and 
overwhelming  the  family  with  their  complaints.  Such  is  the  none  too 
flattering  picture  which  is  given  of  them,  in  order  to  make  one  under- 
stand how  disagreeable  their  presence  is;  and,  as  a  matter  of  fact,  to 
superficial  observers  these  changes  in  character  seem  to  be  real.  But 
often  this  is  only  the  case  with  their  intimate  friends,  with  those  in 
whose  presence  ''they  do  not  care  how  they  behave,"  and  not  with 
others.  Does  this  mean  that  the  personality  of  the  patient  has  been 
affected,  and  that  his  qualities  and  failings  considered  intrinsically  have 
been  wholly  changed?  We  do  not  think  so.  Our  good  qualities  and 
our  failings  only  appear  objectively  as  so  many  reactions  of  our  per- 
sonality to  outside  influences.  These  reactions,  for  a  given  individual, 
under  definite  circumstances,  may  be  considered  as  constant.  Neverthe- 
less, in  the  most  sound-minded  individual  these  reactions  differ  accord- 
ing to  the  day  and  to  the  time.  Are  there  not  days  when  one  feels 
nervous,  irritable,  easily  upset,  and  disagreeable?  This  is  why  the  same 
excitation  does  not  always  produce  the  same  impression,  and  why  the 
reaction  varies  with  the  impression  itself. 

This  depends,  first  of  all,  upon  a  mental,  intellectual  factor.  In 
the  impression  there  is  an  element  of  judgment,  and  by  this  very  fact 
the  impression  is  falsified  in  the  case  of  a  neurasthenic.  As  we  have 
seen,  he  has  lost  to  a  more  or  less  marked  degree  the  sense  of  pro- 
portion, so  that  the  same  thing  may  make  either  too  great  or  too  little 
an  impression  upon  him.  Our  patient  may  appear  to  be  moved  out 
of  all  proportion  by  some  trifling  thing,  and  react  emotionally  in  a 
susceptible  or  irritable  way,  while,  on  the  other  hand,  one  thinks  he  is 
lacking  in  feeling,  because  he  has  not  responded  sufficiently  to  some  ex- 
citing event  which  would  normally  have  disturbed  him.  In  reality,  it  is  not 
that  he  has  become  more  peevish  or  more  selfish.  He  has  reacted  to  the 
impressions  which  he  has  received  in  a  manner  which  is  wholly  in 
keeping  with  his  previous  character;  it  is  the  impression  which  has  been 
modified  by  the  mental  condition  of  our  subject.  Still  other  phenomena 
come  in.  It  would  be  a  psychological  error  to  imagine  that,  in  the 
mentality  and  moral  condition  of  an  individual,  an  impression  and  its 
consecutive  reaction  may  be  separated  one  from  another.  In  conscious- 
ness, or  in  the  moral  condition  of  the  moment,  if  one  so  prefers  it,  the 
impression  finds  an  element  of  reinforcement  or  of  inhibition.  If  you 
are  very  preoccupied  and  very  much  obsessed,  an  impression  which 
would  otherwise  have  made  you  quiver  in  response  will  leave  you  per- 
fectly indifferent.  If  you  are  sad  and  discouraged,  you  will  reinforce 
by  this  fact  all  sorrowful  impressions.  Exactly  the  same  thing  is  true 
of  the  neurasthenic,  whose  moral  condition,  being  peculiarly  pessimistic, 
helps  to  magnify  and  exaggerate  all  disagreeable  impressions  and  their 
consequent  reactions,  just  as  the  preoccupations  which  are  obsessing  him 
may  be  of  such  a  nature  as  to  inhibit  and  mask  the  altruistic  tendencies 
which  a  certain  given  stimulus  would  have  called  forth. 
13 


194  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

Another  thing  which  strikes  us  is  the  opposition  which  exists  be- 
tween the  integrity  of  the  psychological  organ  and  the  disturbance  of 
function.  The  whole  problem,  of  the  distinction  between  neurasthenic 
conditions  and  other  conditions  which  border  upon  them  in  certain  of 
their  symptoms  which  are.  but  partly  of  an  organic  nature,  finds  its 
solution  here. 

F.  Phobic  Manifestations. — If  one  sketches  rapidly  a  picture  of 
the  functional  manifestations, — headache,  vertigo,  disturbances  of 
psychic  functions,  disturbances  of  sleep,  disturbances  of  equilibrium, 
pain  in  the  kidneys,  etc., — one  can  easily  see  what  a  large  number  of 
patients  may  be  persuaded  that  they  have  some  organic  affliction  of 
their  nervous  system. 

The  fear  of  madness — and  in  the  neurasthenic  this  is  not  the  be- 
ginning of  wisdom — is  perhaps  one  of  the  most  frequent  forms  under 
which  these  phobic  localizations  are  expressed.  This  is  because  the 
patients  have  no  difficulty  in  perceiving  that  they  are  not  quite  as  well 
under  self-control  as  they  were.  The  modifications  of  their  emotional 
condition  as  well  as  their  intellectual  state  do  not  escape  them.  *'I 
have  a  dread  of  becoming  mad,"  they  will  tell  you,  repeating  it  until 
you  are  weary  of  it. 

Certain  phobias,  such  as  the  fear  of  committing  suicide  or  some 
particular  criminal  deed,  encourage  them  in  this  conviction.  They  have 
then  all  the  greater  fear  of  losing  their  self-control  because  they  are  in 
dread  that  their  theoretic  unconsciousness  will  lead  them  to  perform 
some  dangerous  act,  either  to  themselves  or  to  others. 

But  under  the  influence  of  these  preoccupations  a  whole  series  of 
secondary  phenomena  appear. 

On  the  one  hand,  it  is  the  moral  condition  which  is  still  depressed. 
On  the  other,  as  a  direct  result  of  self -scrutiny  aroused  by  auto- 
suggestion, it  is  a  peculiar  aggravation  of  all  psychic  manifestations. 
Being  anxious  to  know  that  his  intelligence  is  normal,  his  comprehension 
intact,  his  manner  of  speaking  natural,  and  his  explanations  sufficiently 
clear,  the  patient  will  by  this  very  inquiry  inhibit  the  majority  of  his 
faculties.  One  can  easily  see  that  this  is  not  the  method  one  would 
choose  in  order  to  sharpen  one's  comprehension  or  make  one's  conversa- 
tion brilliant,  to  be  continually  asking  oneself  if  one  is  able  to  under- 
stand, and  if  every  word  which  one  uses  corresponds  exactly  with  the 
thought  which  one  wishes  to  express.  Patients  in  this  way  get  into  a 
vicious  circle.  Their  uneasiness  as  it  grows  at  the  same  time  increases 
the  various  objective  and  subjective  manifestations  which  formed  its 
starting-point.  Things  may  go  on  in  this  way  until  matters  have  been 
pushed  pretty  far.  By  his  preoccupations  the  patient  withdraws  him- 
self from  his  daily  environment — from  his  business,  from  his  circle 
of  friends.     The  most  sinister  resolutions  may  run  through  his  mind. 


NERVOUS  AND  PSYCHIC  MANIFESTATIONS.  195 

We  must  hasten  to  add,  however,  that  he  never  carries  them  out. 
However,  he  is  none  the  less  profoundly  miserable  and  worthy  of  pity. 

Sometimes  the  only  thing  that  has  been  necessary  to  bring  about 
the  lamentable  result  is  a  medical  examination  which  has  been  a  little 
too  pointed  in  its  special  direction,  and  which  has  ser\^ed  to  centre  the 
patient's  mind  upon  the  conditions  of  his  faculties  for  much  too  long  a 
time. 

Nevertheless,  things  do  not  usually  go  quite  so  far.  It  generally 
happens  that  patients,  instead  of  becoming  uneasy  about  their  mental 
condition  taken  as  a  whole,  become  interested  only  in  one  or  another 
of  their  faculties.  There  are  some  who  in  this  way,  and  by  the  very 
mechanism  of  inhibition  under  the  influence  of  preoccupation,  will  get 
to  such  a  point  where  they  will  more  or  less  practically  cease  to  use 
this  or  that  cerebral  function  of  reception,  elaboration,  or  transmission. 

Attention  deafness  and  attention  blindness  may  thus  be  created  by  a 
process  inverse  to  that  of  distraction,  which  we  have  already  pointed 
out.  A  certain  patient,  convinced  that  he  does  not  understand  very 
well  what  is  said  to  him,  will  really  have  some  trouble  in  following  an 
explanation  or  a  lecture,  because  he  will  pay  too  close  attention  to  it. 
He  will  no  longer  perceive  words,  but  rather  sounds,  like  an  individual 
whose  ears  are  strained  to  catch  the  slightest  noise  who  will  not  grasp 
words  which  may  be  addressed  to  him  quite  near  by.  In  the  same  way 
he  may  be  able  to  see  signs  whose  signification  he  does  not  understand 
for  the  same  reasons. 

Other  patients  declare  that  they  are  incapable  of  connecting  their 
ideas.  Some  pretend  that  this  or  that  creative  faculty  is  peculiarly 
restricted.  This  one  says  that  it  is  impossible  for  him  to  make  any 
calculations;  another  avers  that  he  cannot  write  a  business  letter; 
another  claims  to  have  lost  his  memory;  a  fourth  wiU  state  that  he 
can  no  longer  express  himself  clearly  and  that  he  stutters  and  stumbles 
when  he  speaks.  One  may  see  every  variety.  There  are  no  cerebral 
functions  which  may  not  become  effective  either  alone  or  with  the  most 
varied  associations.  **Not  here,"  because  under  the  influence  of  pre- 
occupations of  another  kind  the  patient's  attention  is  wandering,  and 
he  is  put  *  '  somewhere  else,  "  as  we  said  before.  The  phenomenon  in  this 
case  is  quite  the  opposite.  It  is  oiie  of  concentration  on  the  function 
itself,  from  which  results  a  peculiar  disturbance  in  the  exercise  and  in 
the  objective  and  subjective  practice  of  this  function. 

Less  frequently,  but  still  very  often,  one  meets  with  patients  whose 
attention  has  become  side-tracked  concerning  the  existence  of  some 
organic  affection  of  the  brain.  General  paralysis,  congestion,  haemor- 
rhage, softening  of  the  brain,  and  cerebral  arteriosclerosis  are  among 
the  affections  with  which  certain  patients  actually  believe  themselves 
to  be  afflicted  or  are  on  the  verge  of  contracting. 

And  although  there  are  a  certain  number  of  pseudo-neurasthenics 
who  are  merely  weak  by  reason  of  vascular  insufficiency,  there  is  a 


196  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

much  greater  number  of  patients  who,  either  spontaneously  or  from  out- 
side-suggestive influences,  take  care  of  themselves  in  order  to  ward  off  or  to 
cure  purely  imaginary  maladies. 

The  psychic  orientation  of  the  patient  responds  to  various  mechan- 
isms. Medical  intervention  plays  a  by  no  means  negligible  rôle.  We 
have  seen  a  great  number  of  subjects  who,  being  simple  neurasthenics, 
have  had  their  psychological  troubles  cast  up  to  the  account  of  pre- 
cocious arteriosclerosis.  The  clinical  diagnosis  is  confirmed  by  the 
therapeutic  measures  to  which  they  have  been  submitted, — lacto- 
vegetarian  régime,  treatment  by  iodides,  arsonvalization,  etc., — ^so  much 
so  that  at  every  hour  of  the  day  the  patient  was  obliged  to  recall  that 
he  was  arteriosclerotic,  which  was  hardly  the  best  thing  to  improve  his 
moral  tone  and  to  distract  him  from  his  condition. 

Sometimes  medical  practitioners  have  aggravated  matters,  for  they 
have  not  refrained  from  speaking  to  the  patient  of  congestion,  and 
haemorrhage,  and  paralysis  which  is  lying  in  wait  for  him  if  he  does 
not  take  care  of  himself  regularly.  Is  anything  more  needed  to  fix  a 
neurasthenic 's  mind  and  give  him  obsessions  ? 

In  other  cases,  it  is  the  symptomatology  itself  which  becomes  the 
starting-point  for  preoccupations  of  our  subject.  Vertigoes  have  always 
seemed  to  us  to  play  a  preponderant  rôle  along  this  line.  Sometimes 
it  is  a  slight  congestion  which  follows  a  meal,  sometimes  insomnia, 
sometimes  the  disturbances  of  psychological  functions  themselves  which 
play  the  rôle  of  primum  mohile  for  this  fixation.  Elsewhere  it  is  the 
memory  of  an  unfavorable  heredity  of  some  more  or  less  remote  an- 
cestor which  haunts  the  patient.  Sometimes  it  is  syphilis,  either  estab- 
lished or  merely  possible,  which,  in  an  individual  who  knows  the  cerebral 
consequences  which  may  follow  this  affection,  attributes  the  symptomatic 
neurasthenic  sensations  experienced  by  the  patient  to  a  slowly  develop- 
ing general  paresis.  Such  a  mechanism  is  also  frequent  among  phys- 
icians themselves,  and  we  have  seen  very  well-educated  colleagues  of 
excellent  intelligence  spend  whole  hours  in  examining  their  pupils,  test- 
ing their  knee-jerks,  or  listening  to  themselves  speak,  to  see  if  they 
were  not  dysarthric.  Old  syphilitics  who  are  accidentally  over-fatigued 
are  seized  by  the  idea  of  a  possible  general  paresis,  and  it  is  in  this 
way  that  they  gradually  get  into  a  neurasthenic  condition  which  in  such 
cases  is  secondary. 

It  is  hardly  necessary  to  say  that,  once  the  patientas  mind  has  be- 
come fixed  in  this  way,  the  symptoms  of  localization  will  grow  and 
multiply.  The  attacks  of  dizziness  will  become  more  frequent  and  occur 
at  any  hour  of  the  day  ;  patients  will  begin  to  complain  of  disturbances 
which  they  attribute  sometimes  to  anaemia  and  sometimes  to  congestion. 
All  the  little  congestive  pressures  which  are  so  common  even  in  healthy 
people  will  receive  the  most  careful  consideration. 

Briefly  speaking,  the  patient  will  be  in  a  fair  way  toward  establishing 
a  complete  systematization.     He  will  live  for  his  malady,  and  his  very 


NERVOUS  AND  PSYCHIC  MANIFESTATIONS.  197 

existence  will  centre  upon  it.  He  will  think  that  he  is  going  to  die  soon, 
and  dwell  upon  the  possibility  of  sudden  death,  in  view  of  which  he 
will  put  his  affairs  in  order.  He  will  behave  really  like  a  hypochondriac. 
But  once  again  we  must  insist  that  none  of  these  manifestations,  any 
more  than  all  the  others  which  we  have  studied,  are  signs  of  hypo- 
chondria, properly  speaking,  for  the  patient's  mind  is  always  fixed  on 
positive  phenomena  which  really  exist,  but  which  are  interpreted  in  a 
fictitious  way. 

All  these  patients  are  false  cerebrals.  They  are  also  false  meduUaries. 
We  do  not  allude  here  to  the  hysterical  paresthesias  which  are  mis- 
taken in  diagnosis  for  medullary  affections.  We  only  wish  to  consider 
the  phobic  manifestations  which  a  neurasthenic  shows  under  various 
influences. 

An  old  syphilitic  will  be  in  dread  of  the  development  of  tabes.  A 
genital  neurasthenic  will  think  that  his  spinal  cord  is  in  some  way 
affected.  Any  sharp  pains  in  the  kidney  or  rapid  fatigue  on  walking 
will  be  enough  to  turn  the  patient's  mind  toward  the  idea  of  the  pos- 
sible existence  of  some  affection  of  the  spinal  cord. 

Asthenia  alone  might  be  interpreted  as  a  myelopathic  phenomenon. 
The  feeling  that  one  cannot  stand  alone,  as  seen  in  the  phenomenon  of 
stasobasophobia,  may  sometimes  be  the  cause  as  well  as  the  effect  of 
such  a  fixation. 

When  the  patient's  mind  once  becomes  settled  on  such  an  idea,  he 
sees  visions  of  himself  ending  his  days  in  a  wheeled  chair.  The  more 
his  attention  is  drawn  to  his  limbs,  his  fatiguability,  and  his  genital 
functions,  the  more  he  brings  on  himself  distinct  disturbances  of 
equilibrium,  he  grows  tired  more  rapidly,  and  his  sexual  impotence 
really  appears. 

Other  phobic  manifestations,  which  are  really  much  more  frequent 
among  people  who  are  slightly  disturbed  mentally  than  even  among 
pronounced  neurasthenics,  seem,  however,  to  be  easily  produced  in  this 
latter  class  of  patients,  but  in  an  episodic  fashion.  We  refer  here  to 
agoraphobia,  and  the  various  phobias  connected  with  open  spaces,  cross- 
ing streets,  and  danger  of  carriages.  They  may  have  a  common  origin 
in  the  fear  of  accident.  The  patient  who  thinks  that  he  has  some  con- 
gestions and  who  is  afraid  of  suddenly  losing  consciousness,  or  who 
knows  himself  to  be  liable  to  attacks  of  giddiness  or  sudden  exhaustion, 
grows  more  and  more  unwilling  to  run  any  risk  by  going  out  of  doors. 
First  of  all,  he  will  assure  himself  of  the  possibility  of  help  in  case  of 
accident.  He  will  take  every  precaution  that  his  identity  could  easily 
be  established  if  such  an  accident  should  occur.  Under  these  conditions 
he  will  dare  to  go  for  a  certain  distance.  But  he  will  not  be  able  to 
accomplish  this  without  very  great  uneasiness,  which  will  quickly  ex- 
haust his  strength  and  make  him  still  more  fearful  about  his  next  walk. 
Little  by  little  he  will  get  to  the  point  where  he  will  no  longer  go  out 
of  his  house,  or  at  least  will  not  dare  to  walk  anywhere  except  upon 


198  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

grounds  which  are  surrounded  by  walls.  Thus  limited  in  all  his 
activities  and  more  or  less  continually  in  a  state  of  anxiety,  it  will  not 
be  long  before  he  is  profoundly  depressed. 

We  do  not  wish  to  close  this  chapter  without  remarking  that  it  is 
almost  impossible  to  make  any  artificial  distinction  which  would  separate 
these  nervous  or  psychic  symptoms  from  one  another.  Clinically  they 
react  upon  one  another  and  are  reciprocally  created  and  strengthened. 
Finally,  they  may  get  to  the  point  where  they  form  a  very  full  and 
complex  symptomatology,  and  it  is  extremely  difficult  to  establish  the 
exact  course  which  the  successive  manifestations  take.  And  it  seems  to 
us  that  it  is  often  because  of  this  difficulty  of  the  psychological  analysis 
of  things  that  so  many  neurasthenic  troubles  are  attributed  to  phenom- 
ena of  an  organic  nature.  If  they  were  better  followed  out,  their  psychic 
origin  would  be  very  clearly  apparent.  The  neurasthenic  who,  looked 
at  synthetically,  may  appear  to  be  an  organic  will  always  on  analysis 
reveal  himself  as  a  psychic.  The  whole  thing  is  to  push  the  analysis 
sufficiently  far  so  as  to  be  able  to  get  at  the  true  nature  of  things. 


CHAPTER  XL 

FUNCTIONAL  MANIFESTATIONS  AND  ORGANIC  STATES. 

The  relations  between  functional  manifestations  and  organic  states 
are  relatively  very  complex.  Many  questions  arise  in  fact.  In  what 
measure  are  functional  manifestations  liable  to  create  organic  conditions 
either  directly  or  indirectly? 

First  of  all,  there  is  emotional  shock  which  may  act  in  two  different 
ways,  either  by  creating  of  itself  the  succeeding  organic  condition  or 
by  acting  only  as  an  occasional  cause  in  such  subjects  as  are  predis- 
posed to  the  appearance  of  this  or  that  symptom. 

It  is  thus  that,  among  those  who  are  predisposed,  emotion  may  be 
the  occasion  of  the  first  attack  of  angina  pectoris,  or  a  first  attack  of 
hepatic  or  renal  colic,  or  of  a  cerebral  haemorrhage,  in  subjects  whose 
heart,  liver,  kidneys,  or  brain  are  far  from  being  immune.  By  reason 
of  the  vasomotor  phenomena  and  the  spasmodic  contractions  that  a 
strong  emotion  brings  in  its  train,  certain  symptoms  may  be  started 
up  which  had  hitherto  existed  potentially  in  the  individuals  thus 
afflicted. 

Exophthalmic  goitre  and  jaundice,  under  certain  circumstances,  ap- 
pear to  be  direct  and  immediate  results  of  strong  emotion.  Emotional 
jaundice  has  been  known  for  a  long  time.  Rapidly  developing  blindness 
has  likewise  been  established  as  following  emotional  shock. 

Although  the  pathogeny  of  these  latter  cases  is  still  very  obscure,  it 
is  no  less  certain  that  the  emotion  and  the  organic  upsetting  which  it 
causes  may  really  be  expressed  by  conditions  which  last  for  a  long  time, 
and  which  take  organic  expression.  This  is  because  there  are  in  emotion 
certain  organic  factors,  certain  somatic  modifications,  which  are  really 
functional,  but  which  are  susceptible  of  having  many  objective  con- 
sequences. Emotion,  in  other  words,  is  capable  of  acting  on  the 
organism  like  an  infection  or  an  intoxication.  The  rôle  of  emotional 
shock  in  the  determination  of  a  rather  large  number  of  organic  symp- 
toms is  admitted  by  nearly  everybody,  although  they  are  scarcely  aware 
of  the  fact. 

What  action  prolonged  emotional  conditions  may  exercise  on  the 
organism  is  more  open  to  discussion.  The  immediate  expression  of  these 
conditions  appears,  as  a  rule,  in  functional  manifestations  of  every 
kind.  We  have  already  studied  the  majority  of  these.  It  now  remains 
for  us  to  know  whether  functional  manifestations  may  more  or  less 
slowly  arrive  at  the  point  of  becoming  organic  conditions. 

It  is  certain  that,  if  we  refer  to  statistics,  emotions  which  have  been 
nursed  along  seem  to  come  in  as  an  etiological  factor  in  a  considerable 
number  of  affections.    It  is  not  merely  a  figure  of  rhetoric  when  it  is 

199 


200  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

said,  as  it  often  is,  that  there  are  people  who  ''die  of  grief.'*  The 
popular  expression  corresponds  to  an  objective  reality.  One  must  needs 
be  a  very  poor  observer  or  to  have  never  known  life  if  one  has  not  seen 
people  who  seem  to  have  been  unable  to  ''pull  themselves  together" 
after  experiencing  some  great  grief.  But  it  seems  to  us  that  in  such 
cases  the  emotion  does  not  act  directly;  more  often  it  is  by  the  inter- 
mediary steps  of  more  or  less  marked  malnutrition  that  such  people, 
having  become  less  resistant,  easily  fall  a  prey  to  disease.  As  for 
those  conditions  of  malnutrition  themselves,  there  is  no  doubt  that 
they  are  directly  due  to  emotional  conditions.  We  have  already  said 
that  nothing  is  so  easily  influenced  by  emotion  as  the  appetite.  It  is 
also  true  that  people  who  are  preyed  upon  by  grief,  emotions,  and  cares 
no  longer  take  enough  food,  and  this  is  the  mechanism  of  malnutrition 
which  affects  them,  and  the  diseases  which  follow. 

We  would  like  to  go  still  a  little  further  along  this  line.  It  seems 
to  us  that,  under  psycho-secretory  influences  and  because  there  is  a 
feeling  of  disgust  for  food  while  one  is  eating,  there  may  be  in  certain 
people  a  condition  of  insufficient  assimilation.  Such  individuals  may 
eat  in  vain,  and,  as  one  commonly  says,  "their  food  does  them  no 
good.  '  '  They  continue  to  grow  thinner  as  long  as  they  are  preoccupied 
and  obsessed,  and  this  is  a  second  mechanism  by  which,  in  a  mediatory 
way  it  is  true,  but  none  the  less  effective,  continued  emotional  states 
may  be  the  accompanying  condition  of  a  great  many  affections.  Might 
we  go  still  a  little  further,  and  imagine  that  the  emotional  condition  in 
itself  renders  the  individual  less  resistant  to  acute  diseases,  that,  in 
other  words,  the  combination  of  organic  reactions  which  struggle  against 
the  disease  are  found  to  be  too  weak  to  conquer  in  the  presence  of  an 
emotional  condition?  If  we  are  to  believe  popular  tradition  and  read 
certain  stories  of  epidemics,  we  would  be  tempted  to  reply  positively. 
But  it  is  more  than  probable  that  it  is  by  the  intermediary  steps  of 
mental  disturbances — ^that  is  to  say,  the  condition  of  moral  depression 
— which  bring  with  them  emotion  or  preoccupation,  that  such  phenom- 
ena will  be  sustained.  When  one  is  worried  or  preoccupied,  one  is  in 
no  mood  to  fortify  oneself  against  disease,  and  against  all  the  external 
and  modifiable  causes  upon  which  it  may  depend.  The  history  of  armies 
conquered  and  decimated  by  disease  is  another  instance  that  shows  us 
the  importance  which  the  moral  tone  plays  as  a  factor  of  physical 
resistance. 

On  the  other  hand,  in  such  a  domain  it  is  not  to  be  hoped  that  we 
can  ever  find  cases  so  distinct  that  they  would  bring  conviction.  For 
our  own  part,  we  think  that  it  is  essentially  by  the  intermediary  steps 
of  malnutrition  which  continued  emotions  (or  preoccupations,  if  one  so 
prefers  to  call  them)  bring  about  that  they  are  able  to  exert  such  an 
influence  on  the  eventual  development  of  serious  organic  affections. 

On  the  other  hand,  there  seems  to  us  no  doubt  that  a  whole  series 
of  bad  habits,  vicious  attitudes,  and  disharmonies  of  all  kinds,  which 


MANIFESTATIONS  AND  ORGANIC  STATES.  201 

the  various  functional  manifestations  are  able  to  create  and  develop, 
may  in  a  large  measure  come  in  to  help  the  development  of  organic 
affections.  It  is  very  evident,  for  example,  that  a  person  who  is  under 
the  influence  of  some  continued  oppression  of  emotional  origin  breathes 
badly,  and  by  this  fact  alone  will  more  easily  become  the  prey  of 
tuberculosis,  against  which  he  would  otherwise  have  been  better  pro- 
tected. In  all  the  domains  of  functional  manifestations  which  we  have 
successively  examined,  we  may  find  analogous  examples. 

We  do  not  insist  upon  this,  and  we  must  content  ourselves  by  say- 
ing that  from  the  organic  point  of  view  a  continued  emotional  condition 
or  a  preoccupation  is  by  no  means  a  trifling  thing,  and  that  in  all  cases 
it  is  a  factor  which  must  not  be  systematically  neglected. 

The  most  interesting  of  these,  it  seems  to  us, — because  it  is  much 
the  most  positive, — is  the  grafting  of  neurasthenic  conditions,  or  hys- 
terical manifestations,  on  to  antecedent  organic  states. 

We  do  not  attach  much  weight  to  hystero-organic  associations.  We 
know  what  they  consist  of.  An  individual  is  attacked  by  an  organic 
hemiplegia.  A  homonymous  hysterical  hemianesthesia  is  superposed 
on  a  paralysis  ;  there  may  be  besides  a  contracture  or  hysterical  paralysis 
complicating  a  neuralgia,  etc.  The  association  is  only  of  interest  from 
a  diagnostic  point  of  view.  As  far  as  the  psychogenesis  of  the  sjmip- 
toms  is  concerned,  all  the  elements  which  we  have  already  studied,  re- 
inforced by  the  existence  of  some  real  thorn  in  the  flesh,  will  find  them- 
selves there  in  full  force.  In  these  associations  we  must  say  the  part 
played  by  simulation  or  suggestion  is  much  greater  than  in  the  hysterical 
symptoms  due  to  an  emotional  traumatism. 

On  the  contrary,  the  organic  neurasthenic  association  seems  to  us 
very  important.  It  is  one  of  the  most  frequent,  and,  moreover,  is  of 
considerable  theoretical  interest. 

It  is  a  very  curious  psychological  study  to  understand  the  minds 
of  a  great  many  physicians  who  are  wholly  engrossed  with  organic  dis- 
ease. The  very  men  who  are  treating  pure  neurasthenics  by  the  most 
complex  medical  therapeutics  and  without  paying  any  attention  to  their 
mental  condition,  if  they  have  a  patient  who  is  tuberculous  or  a  cardiac, 
will  impress  upon  him  the  necessity  of  rest,  moral  calm,  and  a  life  free 
from  care  and  emotions  and  preoccupations.  They  freely  admit  that 
all  these  factors  are  able  to  modify  and  aggravate  an  organic  condition. 
Why  do  they  not  perceive  that  it  is  the  same  thing  as  admitting  that 
these  cares,  emotions,  and  preoccupations  are  likely  to  create  outside 
of  all  organic  associations  a  symptomatology  of  their  own?  As  a 
matter  of  fact,  when  does  a  physician  ever  say  to  his  patient  who  is  a 
cardiac  or  tuberculous,  etc.,  *  '  Now,  see  here,  you  are  not  going  to  become 
neurasthenic  over  this?"  Is  it  when  he  has  detected  some  disturbance 
of  internal  secretory  glands,  or  a  dilated  stomach,  or  intestinal  fermenta- 
tion? Is  it  even  when  he  has  noticed  an  unreasonable  amount  of 
fatigue,  or  too  rapid  exhaustion  in  his  patient?     Not  at  all.     It  is 


202  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

always — whatever  may  be  his  particular  idea  of  isolated  neurasthenic 
conditions — ^when  he  sees  that  the  moral  condition  of  his  patient  is 
growing  weak  and  his  emotionalism  is  increasing.  The  same  physician 
who  feels  that  the  bodily  mentality  may  be  explained  by  the  associated 
lesion  will  make  an  appeal  to  the  patient's  energy,  to  his  will,  to  his 
reason,  to  his  self-confidence.  He  will  strengthen  it  and  reinforce  it; 
but,  if  he  is  in  the  presence  of  a  pure  neurasthenic  in  whom  he  finds 
no  organic  lesion,  he  will  give  him  arsenic,  phosphates,  lecithin,  and 
will  exhaust  the  whole  medical  arsenal  without  paying  the  slightest 
attention  to  the  patient 's  state  of  mind.  So  much  for  the  logic  of 
things. 

But  let  us  return  to  the  objective  study.  First  of  all,  by  what 
mechanism  does  a  person's  body  gradually  become  neurasthenic?  There 
is  .only  one  constant  and  necessary  intermediary.  This  is  preoccupa- 
tion. It  may  be  connected  with  the  patient's  state  of  health  and  be 
centred  around  his  fears  for  his  life  or  for  his  future.  It  may  be  fixed 
on  any  symptom  whatever  of  the  affection  in  process  of  evolution. 

Any  painful  symptom  is  particularly  apt  in  this  way  to  become 
the  starting-point  of  obsessions.  Then  the  consequences  of  the  disease 
may  become  factors  of  the  preoccupation.  One  feels  that  one  is  a  care 
to  one 's  family,  one 's  business  has  come  to  a  stand-still  or  is  in  jeopardy, 
or  one  is  fearful  of  infecting  the  people  around  him.  Sentiments  of 
a  less  praiseworthy  nature,  such  as  conjugal  jealousy,  may  come  in  to 
play  their  rôle.    . 

From  thenceforth,  under  the  influence  of  neurasthenic  association, 
the  organic  affection  which  is  developing  may  be  singularly  modified. 

Let  us  take,  in  order  to  press  these  ideas  home,  a  tuberculous 
patient — and  upon  this  subject  Eenon  has  written  very  wisely — who 
has  become  neurasthenic.  His  appetite,  which  has  already  often  been 
affected,  will  become  still  poorer.  He  will  no  longer  eat  as  he  should, 
and  will  add  disturbances  of  true  mental  anorexia  to  the  disturbances 
of  appetite  caused  by  the  disease  itself.  We  can  readily  see  that  under 
these  conditions  he  will  fail  much  more  rapidly  and  that  the  prog- 
nosis will  be  distinctly  less  helpful.  If  he  has  a  fever  or  an  obstinate 
cough,  or  intercostal  neuralgia,  he  may  become  obsessed  upon  one  or 
the  other  of  these  symptoms.  He  will  cough  much  more  often  than  is 
necessary,  because  he  will  be  listening  to  see  how  bad  it  is.  His  neural- 
gia, which  until  that  time  had  been  intermittent  and  not  very  trouble- 
some, will  become  intolerable  and  continuous,  because  he  will  think  of 
it  all  the  time,  and  he  will  suffer  from  it  in  memory  as  he  would  suffer 
from  the  actual  pain. 

Let  us  take  a  convalescent  recovering  from  some  acute  disease. 
Instead  of  his  being  able  to  regain  his  health  completely  in  a  few 
days  or  weeks  perhaps,  it  will  take  him  several  months.  The  asthenia 
of  the  neurasthenic  is  superimposed  on  the  asthenia  of  convalescence. 
His  first  steps  will  be  much  more  hesitating  and  wearisome  if  he  is 


MANIFESTATIONS  AND  ORGANIC  STATES.  203 

afraid  than  if  he  starts  forth  deliberately.  Whatever  habits  he  has 
contracted  during  the  course  of  his  disease  will  be  hard  to  get  rid  of. 
Long  after  he  has  been  cured  of  his  organic  trouble  he  will  still  remain 
a  functional. 

Here  is  a  cardiac  who  knows  that  he  has  heart  disease  and  who 
lives  in  terror  of  the  idea  of  sudden  death.  It  is  very  evident  that  the 
emotional  tachycardia  which  he  will  show  on  the  occasion  of  the  slightest 
palpitation  will  not  improve  his  cardiac  contraction  and  that  his  moral 
condition  will  not  be  any  the  better  for  his  feeling  his  pulse  all  day  long. 

A  urinary,  who  thinks  of  his  prostate  or  of  the  contraction  of  his 
urethra,  will  graft  on  to  his  organic  condition  superadded  functional 
manifestations.  In  this  way  he  may  add  a  great  many  complications 
to  his  organic  symptomatology.  As  retention  of  the  urine  is  often  the 
result  of  unconscious  contractions,  it  may  also  be  the  result  of  con- 
tractions due  to  a  phobia,  because  the  patient  does  not  dare  to  urinate 
or  because,  being  convinced  of  his  lack  of  power,  he  inhibits  the  need 
he  may  feel. 

It  is  a  mere  commonplace  to  say  that  in  all  organic  affections  of 
gait  a  functional  element  is  always  superimposed  upon  the  troubles 
which  are  there  **by  right."  It  is  on  this  principle  that  elsewhere  all 
the  so-called  re-educational  methods  have  been  based.  There  are 
innumerable  subjects  attacked  by  spasmodic  paraplegia,  for  example, 
who,  though  able  to  walk  very  well  in  their  apartment,  feel  their  limbs 
give  w^ay  from  under  them,  or,  so  to  speak,  find  them,  on  the  contrary, 
rooted  to  the  earth,  as  soon  as  they  have  to  walk  in  the  street  without 
being  supported  by  some  one.  One  often  sees  patients  of  this  kind  in 
whom  at  least  the  half  of  their  motor  helplessness  is  purely  phobic  in 
its  origin.  The  same  thing  is  true  in  many  ataxics.  In  all  these  cases 
motor  re-education  combined  with  psychotherapy  gives  very  good 
results. 

There  are  no  organic  conditions  which  may  not  be  multiplied  or 
diffused  in  some  way  by  the  addition  of  functional  manifestations,  as 
there  are  no  functional  manifestations  which  one  may  not  find  super- 
posed upon  an  organic  defect. 

A  very  interesting  point  to  study  is  the  future  of  these  morbid  asso- 
ciations. Organic  affection  may  by  the  very  force  of  things  become 
cured,  and  the  neurasthenic  condition  persist  in  its  functional  mani- 
festations. Numerous  topalgias  and  pains  sine  materia  seem  to  us  to 
be  of  such  origin.  There  are  individuals  who  for  months,  even  years, 
continue  to  suffer  in  some  organ  or  some  region  or  point  which  is  no 
longer  the  seat  of  any  real  morbid  disturbance.  These  are  subjects 
who  have  grafted  an  obsession  on  some  passing  disturbance,  and  who, 
so  to  speak,  continue  to  suffer  in  memory.  Among  the  very  theoretic 
*' painful  adhesions"  a  great  number  seem  to  us  to  spring  purely  and 
simply  from  this  mechanism. 

Other  persons  who  have  long  since  been  cured  continue  indefinitely 


204  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

to  nurse  themselves.  It  is  not  that  they  are  still  suffering  from  any 
pain  or  persistent  morbid  disturbance:  it  is  a  habit  which  they  have 
formed  and  from  which  they  cannot  free  themselves. 

Finally,  there  are  people  who  after  a  disease,  and  because  they  have 
established  a  neurasthenic  association,  preserve  the  mentality  of  illness. 
They  have  left  their  energy,  and  their  will,  their  physical,  intellectual, 
and  moral  aptitudes,  behind  in  their  illness,  because  they  have  formed 
the  habit  of  auto-observation,  of  lack  of  confidence  in  their  strength, 
and  the  conviction  that  all  their  efforts  are  useless,  and  they  do  not 
know  how  to  get  rid  of  these  impressions. 

It  is  by  phenomena  of  this  kind  that  we  ought  to  interpret  all  the 
neurasthenias  which  follow  illness.  In  these  cases  the  condition  that 
follows  some  organic  disease,  such  as  typhoid  fever,  or  anything  like 
that,  is  not  due  to  any  material  disturbance  of  functions;  it  is  a 
modification  of  the  moral  and  physical  condition. 

Setting  aside  all  reserves  on  the  possible  existence  of  lesional  troubles 
of  an  emotional  origin,  the  thing  that  constitutes  the  great  interest  in 
the  study  of  these  organic  and  functional  associations  is  that  it  is  very 
clear  that  neurasthenic  symptoms  are  only  superposed  upon  the  organic 
symptomatology  when  there  are  changes  in  the  moral  and  psychic  state 
of  the  individual. 


CHAPTER  XII. 

GENERAL  DIAGNOSIS  OF  FUNCTIONAL   MANIFESTATIONS. 

It  IS  evident  that  functional  manifestations  do  not  exist  independently. 
They  are  closely  bound  up  with  the  neurasthenic  or  hysteric  condition 
which  has  engendered  them.  There  is,  therefore,  no  doubt  that  in  many 
circumstances  it  is  a  neurasthenic  condition  or  the  hysterical  mentality 
of  the  subjects  having  such  symptoms  which  is  the  chief  sign  that  points 
to  the  diagnosis.  But  this  is  not  the  point  which  we  wish  to  consider 
now:  we  shall  return  a  little  later  to  take  up  this  broad  question  of 
the  diagnosis  of  hysteria  or  neurasthenia. 

For  the  time  being  we  shall  consider  functional  manifestations  in 
themselves.  We  shall  seek  for  their  principal  characteristics  of  diag- 
nostic value,  and  we  shall  study  how  with  the  help  of  these  charac- 
teristics we  can  differentiate  a  fixation  of  psychic  origin  from  a  morbid 
organic  disturbance  which  may  be  found  associated  with  a  neuropathic 
condition. 

The  first  diagnostic  sign  is  of  a  negative  nature.  If  it  very  fre- 
quently happens  that  nervous  people  are  taken  for  those  who  are 
organically  afflicted,  the  opposite  error  is  also  possible.  Sometimes  the 
whole  symptomatology  may  spring  from  an  organic  affection  in  process 
of  development.  Sometimes  there  exists  some  organic  difficulty,  on 
which  functional  manifestations  have  been  subsequently  engrafted.  The 
real  trouble  is  often  insignificant,  and  of  such  slight  importance  as 
hardly  to  amount  to  anything.  Nevertheless,  it  is  very  important  to 
discover  it,  as  any  misconception  concerning  it  may  bring  about  disaster, 
for  the  patient,  convinced  that  in  spite  of  his  best  efforts  he  has  not 
been  able  to  get  rid  of  some  definite  symptom,  would  rapidly  lose 
confidence  and  be  completely  demoralized. 

This  is  why,  before  even  pronouncing  the  word  neurasthenia,  or  re- 
ferring to  any  neuropathic  symptom  in  words  which  to  our  ideas  carry 
in  themselves  the  requirements  for  an  exclusively  psychic  therapy, 
one  should  examine  his  patient  from  head  to  foot,  and  find  out  whether 
or  not  a  rheumatic  pain,  a  painful  hgemorrhoidal  growth,  a  varicocele, 
enlarged  veins,  or  even  a  com  on  the  foot  may  not  be  the  starting-point 
of  an  almost  purely  psychic  asthenia.  Though  the  organic  part  may 
be  almost  infinitesimal,  nevertheless  it  must  be  taken  into  account. 

A  small  patch  of  eczema,  a  slightly  painful  cheloid,  a  neuralgia,  or 
a  slight  synovitis  may  sometimes  serve  as  a  starting-point  for  very 
serious  and  complex  functional  manifestations.  And,  if  one  does  not 
take  into  consideration  the  organic  element,  it  goes  without  saying  that 
therapeutically  speaking  one  can  have  absolutely  no  success. 

We  are  now  speaking  of  persistent  organic  manifestations,  which 
not  only  might  be  the  starting-point  of  other  symptoms,  but  which 

205 


206  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

also,  by  continually  recalling  the  idea  and  by  attracting  the  patient's 
attention,  may  set  up  and  develop  a  functional  fixation. 

Under  other  circumstances,  it  would  be  necessary  to  make  a  retro- 
spective organic  diagnosis,  and  to  remember  that  the  patient  originally 
had  real  organic  difficulties,  and  that  the  functional  manifestation  is  a^ 
memory,  reinforced  and  diffused,  it  is  true,  but,  in  spite  of  all,  a 
memory  of  a  real  thing. 

As  to  differential  diagnosis  with  an  organic  Eiffection  playing  the 
capital  rôle  in  the  production  of  the  symptomatic  ensemble,  it  is  clear 
that  it  is  a  simple  question  of  objective  examination.  But  sometimes 
this  examination  will  leave  one  in  doubt,  and  then  in  order  to  make  an 
accurate  diagnosis  it  would  be  necessary  to  refer  to  the  positive  char- 
acteristics of  functional  manifestations.  These  latter  are,  moreover, 
sufficiently  distinct  for  one  to  be  able  in  the  greater  number  of  cases  to 
make  a  diagnosis  by  questioning  the  patient. 

A  very  curious  phenomenon  of  medical  mentality  is  the  fact  that 
physicians  hardly  ever  find  out  under  what  circumstances  a  certain 
symptom  appeared.  It  would  seem  as  though  they  regarded  the  moral 
and  emotional  life  on  one  hand  as  separated  by  an  absolute  barrier  from 
the  physical  life  on  the  other  hand.  In  the  presence  of  any  symptom, 
such  as  fatigue,  gastro-  or  enteropathic  pain,  cardiac  or  urinary  dis- 
turbances, the  physician  will  ask  his  patient  when  this  symptom  ap- 
peared for  the  first  time.  He  will  try  to  locate  the  exact  place  in 
which  it  was  felt,  he  will  study  its  characteristics  carefully,  he  will 
make  all  sorts  of  inquiries  about  the  physical  conditions  under  which 
it  appeared  and  its  relations  to  all  the  organic  functions;  but,  when  it 
comes  to  looking  for  any  coordination  whatever  between  the  symptom 
and  the  moral  condition  of  the  patient,  that  is  quite  another  matter. 
One  of  us  has  seen  thousands  of  patients,  of  which  the  majority  had 
consulted  usually  several  physicians.  We  have  known  individuals  who 
had  been  to  as  many  as  twenty  or  thirty  doctors.  One  of  our  patients, 
of  whom  we  have  already  spoken,  was  able  to  give  us  a  list  of  fifty-five 
physicians  whom  she  had  successively  visited  to  consult  about  her  ills. 
But  when  we  try  to  find  out  whether  any  of  these  patients  had  had  any 
questions  asked  them  concerning  their  moral  condition  as  related  to 
their  physical  condition,  not  merely  do  the  majority  but  every  single 
one  of  them  give  us  a  negative  reply. 

This  was  the  response  which  was  called  forth;  it  was  always  the 
same:  *' Doctor,  you  are  the  first  one  who  ever  spoke  to  me  of  my 
feelings  and  mental  state,  or  asked  me  about  the  griefs  or  misfortunes 
which  have  come  to  me  in  my  life.  '  '  Some  patients  would  add,  '  '  They 
often  told  me  that  it  was  merely  that  I  was  nervous,  that  my  nerves 
were  out  of  order,  but  that  was  all." 

There  was  never  any  moral  inquiry  made,  even  by  those  who  most 
carefully  and  conscientiously  made  a  thorough  physical  examination. 
Now,  the  moment  that  one  has  the  slightest  suspicion  that  one  has  a 
neuropath  to  deal  with,  the  first  question  to  put  is  one  which  will  try 


DIAGNOSIS  OF  FUNCTIONAL  J^IANIFE STATIONS.       207 

to  find  out  whether  there  is  any  possible  relation  between  the  symptom 
or  symptoms  of  which  the  patient  complains  and  any  upsetting  event 
in  his  moral  or  emotional  life. 

Any  symptom  which  appears  along  with  an  emotion  or  grief  or  a 
strong  material  preoccupation  is  very  apt  to  become  a  neuropathic 
symptom. 

As  we  shall  see  a  little  further  on,  the  great  majority  of  functional 
manifestations  are  produced  on  bad  moral  soil.  Question  a  false  gas- 
tropath,  or  a  false  enteropath,  and  go  to  the  bottom  of  things  with 
him,  and  you  will  always  find  as  the  starting-point  of  his  symptoms 
either  the  loss  of  money  or  of  a  situation,  or  some  grief.  "I  have  had 
trouble  with  my  stomach  ever  since  my  wife 's  death,  '  ^  this  one  will 
tell  you;  ''I  have  suffered  in  this  way,"  another  one  wiU  say,  ''ever 
since  I  lost  my  position."  Among  women  who  are  pecuUarly  senti- 
mental and  scrupulous,  it  will  sometimes  take  a  long  time  to  ascertain 
the  moral  cause.  Feelings  of  jealousy,  or  scruples  concerning  incomplete 
coitus,  infidelity,  whether  real  or  simply  in  thought,  is  often  enough 
to  start  the  neuropathic  condition  going  with  all  its  secondary  functional 
manifestations. 

Here,  for  example,  are  a  series  of  false  gastropaths  treated  by  one 
of  us  during  a  short  time,  with  the  moral  cause  of  the  difficulty  appended 
in  each  case. 

A  young  man,  twenty  years  of  age,  a  law  student;  genital  pre- 
occupations. 

An  officer,  thirty-six  years  of  age;  preoccupations  concerning  his 
career. 

A  woman,  fifty-six  years  of  age  ;  preoccupied  with  the  future  of  her 
son. 

A  woman,  fifty  years  of  age  ;  false  gastropath  since  the  death  of  her 
husband. 

A  woman,  thirty-two  years  of  age  ;  false  gastro-enteropath  ;  conjugal 
cares. 

A  woman,  twenty-one  years  of  age;  false  gastro-enteropath;  pre- 
occupations concerning  her  mother's  health,  domestic  troubles  arising 
from  misunderstandings  between  the  husband  and  mother-in-law. 

A  man,  fifty-five  years  of  age,  a  political  writer;  false  gastropath 
by  reason  of  genital  preoccupations. 

A  woman,  thirty-six  years  of  age;  false  gastro-enteropath  by  reason 
of  conjugal  worry. 

A  man,  fifty-four  years  of  age,  a  manufacturer;  a  false  gastropath 
with  acute  depression,  both  as  the  result  of  his  financial  losses. 

A  woman,  thirty  years  of  age  ;  a  false  gastropath  as  a  result  of  con- 
jugal unhappiness. 

A  woman,  thirty-seven  years  of  age;  false  gastro-enteropath  as  a 
result  of  deep  grief. 

A  man,  forty  years  of  age;  false  gastropath  following  the  loss  of 
his  mother. — Etc.,  etc. 


208  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

We  might  continue  this  series  indefinitely.  The  moral  cause  is 
always  to  be  found.  Sometimes  the  patient,  being  too  reserved  or  lack- 
ing in  confidence,  will  not  reveal  it  at  once,  and  especially  when,  with 
women  in  particular,  it  is  a  question  concerning  preoccupations  con- 
nected with  the  genital  sphere.  But  it  is  not  necessary  to  have  had  a 
great  deal  of  experience  with  such  patients  to  enable  you  to  feel  that 
they  are  holding  something  back  when  you  question  them.  But  when 
you  really  get  hold  of  your  patient,  he  will  acknowledge  the  cause  which 
ofttimes  he  will  have  hidden. 

The  first  step  in  a  diagnosis,  therefore,  consists  in  finding  out  the 
moral  cause.  This  of  course  is  the  main  element  in  the  diagnosis,  but 
the  study  of  the  functional  manifestation  which  has  been  established 
furnishes  us  with  many  others.  One  of  the  most  important  seems  to 
us  to  be  the  variability  of  the  symptoms,  but  it  is  a  very  peculiar 
variability,  being  so  closely  connected  with  the  moral  condition  of  the 
moment. 

One  of  the  chief  psychotherapeutic  procedures,  as  we  shall  see 
further  on,  consists  in  turning  the  patient's  attention  away  and  dis- 
tracting it  from  his  functional  fixation.  Often  this  may  be  accom- 
plished for  a  time  by  regulating  one's  manner  of  life,  but  without 
therapeutic  intervention  this  does  not  last  long.  There  cannot  help  but 
be  considerable  variation  in  the  intensity  of  the  neuropathic  mani- 
festations, and  once  these  are  brought  out  they  are  often  useful  in 
the  diagnosis. 

Here,  for  example,  is  the  case  of  a  false  cardiac  who  complains  of 
palpitation,  throbbing  of  the  heart,  and  slight  pains.  During  a  certain 
month,  he  will  tell  you,  things  went  better  with  him,  and  then  he 
was  taken  worse  again.  Do  not  follow  this  up  immediately,  but  a  little 
later  bring  your  conversation  round  to  the  subject  of  how  he  spends 
his  days,  try  to  find  out  the  schedule  of  his  life  during  the  weeks  and 
months  that  have  preceded.  You  will  almost  always  find  that  the 
period  of  improvement  coincided  with  some  greater  activity,  or  some 
joy  which  came  to  him.  How  often  it  happens  in  the  same  way  with 
false  gastropaths,  and  false  pathies  of  every  kind,  that  a  happy  marriage, 
an  improvement  in  business  affairs,  or  some  success  has  caused  these 
symptoms  to  disappear  for  a  time,  varying  with  the  degree  of  fixation 
on  the  one  hand  and  the  duration  of  the  ''distraction"  on  the  other 
hand. 

Inversely,  let  a  new  emotion,  an  added  grief,  a  moral  preoccupation 
become  established,  and  the  symptomatology  will  be  intensely  increased. 
**My  husband  fell  ill  six  years  ago,"  one  of  our  patients  told  us.  ''I 
lived  continually  between  hope  and  despair  all  through  his  illness.  Dur- 
ing all  that  time  I  suffered  more  or  less  with  my  stomach,  but  since 
his  death  it  has  become  intolerable." 

A  magistrate,  who  was  a  false  enteropath,  had  suffered  for  twelve 
years  with  indigestion.  Five  or  six  years  before  we  saw  him,  he  had 
had  a  period  during  which  he  was  greatly  relieved;  but  for  the  last 


DIAGNOSIS  OF  FUNCTIONAL  MANIFESTATIONS.       209 

two  years  the  symptoms  had  become  much  sharper.  As  a  matter  of 
fact,  at  the  time  of  his  improvement  he  had  been  very  satisfactorily 
advanced,  while  for  two  years  he  had  been  seeking  in  vain  for  a  more 
suitable  post. 

We  could  go  on  enumerating  these  examples,  but  these  that  we 
have  given  are  enough  to  illustrate  our  idea,  and  to  show  that  the 
functional  manifestation  varies  with  the  moral  condition.  This  is  the 
second  point  in  diagnosis.     But  there  are  still  others. 

The  illogical  combination  of  the  sensations  described  plays  a  role 
w^hich  from  this  point  of  view  is  by  no  means  small.  However  well 
instructed  a  patient  may  be  in  medical  or  surgical  pathology,  it  is  very 
seldom  that  he  gets  to  such  a  point  that  he  may  not  deceive  himself. 
Study  an  algia  in  a  neurasthenic.  Everything  makes  it  worse, — cold, 
heat,  movements,  and  rest.  To  bring  this  about  the  patient  needs  noth- 
ing more  than  to  be  constantly  noting  all  the  modifications  which  his 
pains  may  undergo,  and  thus  fix  his  attention  on  them.  To  pay  atten- 
tion to  them  is  inevitably  to  aggravate  them.  A  false  gastropath  will 
suffer  from  a  test  breakfast,  and  will  tolerate  a  hearty  dinner  providing 
he  has  been  amused  while  eating  it.  A  false  urinary  will  be  able  to 
urinate  easily  at  home,  but  only  with  difficulty  away  from  home,  and 
more  easily  in  the  morning  than  during  the  day.  A  false  cardiac  will 
feel  his  heart  beating  rapidly  when  he  is  sitting  by  his  fireside  and 
examining  it.  If  he  is  prevailed  upon  to  go  out  and  get  a  little  exer- 
cise and  tire  himself,  his  heart  will  be  forgotten  and  will  be  quiet.  All 
functional  manifestations  offer  us  a  study  of  similar  phenomena.  The 
lack  of  logic  is,  moreover,  always  apparent.  It  is  this  lack  of  logic 
relating  to  what  one  knows  of  those  organic  manifestations,  by  which 
one  is  aided  in  making  a  diagnosis.  But  when  one  knows  that  in  a 
functional  localization  everything  that  fixes  the  patient's  attention  leads 
up  to  or  reinforces  the  symptoms,  one  understands  that  this  lack  of  logic 
is  so  necessary  and  inevitable  that  the  patient  who  is  the  most  organically 
suggestible  will  be  taken  in  by  it.  It  furnishes  at  the  same  time  an 
excellent  aid  to  diagnosis  to  the  physician  who  is  examining  him. 

Too  many  symptoms  is  another  thing  which  one  finds  almost  con- 
stantly in  the  picture  of  functional  manifestations.  Patients  who  have 
read  and  who  have  picked  up  a  considerable  number  of  ideas  concerning 
medical  pathology  in  doctors'  offices  progressively  practise  auto-  and 
hetero-suggestion.  There  is  no  symptom  which  a  doctor  has  tried  to 
find  in  them  but  that  they  finally  experience,  and,  although  this  symp- 
tomatology is  more  often  apt  to  be  quite  illogical,  combining  char- 
acteristics of  different  affections  which  could  not  belong  to  one  another, 
it  also  happens  that  it  may  be  too  logical  and  too  classic  when,  for 
instance,  a  physician  has  been  called  in  and  has  given  a  precise  diag- 
nosis. The  case  then  rapidly  becomes  too  perfect  and  typical  to  be 
true.  When  you  find  yourself  in  the  presence  of  a  patient  who  recites  his 
symptomatology  as  glibly  as  a  medical  student  would  rattle  off  symp- 
14 


210  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

toms  in  a  quiz,  if  no  objective  sjonptoms  are  experienced,  in  the  ma- 
jority of  instances  it  is  apt  to  be  a  case  of  functional  disturbance. 

A  false  gastropath,  or  a  false  enteropath,  who  has  been  treated  by  a 
specialist  will  present  quite  too  precise  a  symptomatology,  but  if  he 
has  been  under  the  care  of  a  physician  who  was  less  informed  he  will 
offer  a  more  diffuse  and  rather  cumbersome  symptomatology. 

Functional  associations  constitute  still  another  element  of  diagnosis. 
It  is  rare  in  fact  that  these  patients  are  monosymptomatic.  The  digestive 
symptoms  perhaps  are  the  only  ones  that  often  occur  independently. 
Nearly  all  the  other  functional  manifestations  are  grouped  together  and 
increase  and  multiply. 

Digestive  disturbances  are  apt  to  become  coupled  with  genital  fixa- 
tions, and  the  latter  may  become  complicated  by  urinary  symptoms. 
Cardiac  disturbances  and  respiratory  troubles  lead  to  general  asthenia, 
etc.  Every  simple  and  complex  association  that  exists  may  be  found 
in  these  eases. 

We  shall  have  finished  with  this  chapter  on  diagnosis  when  we 
add  that  we  have  omitted  the  most  important  factor, — namely,  the 
moral  and  mental  condition  of  the  subject  in  whom  the  neuropathic 
symptoms  are  manifested.  But  we  shall  take  up  these  conditions  at 
much  greater  length  further  on,  as  well  as  the  peculiar  habits  or  man- 
nerisms that  they  give  to  patients,  and  which  often  give  us  the  cue  at 
the  start,  so  that  during  the  first  examination  of  the  subject  we  are 
often  convinced  that  we  have  a  neuropath  to  deal  with. 

There  remains  one  last  point  for  us  to  study.  It  concerns  the  dif- 
ferentiation to  be  made  between  hysterical  symptoms  and  simulation. 
Some  authors  avail  themselves  of  a  very  simple  solution,  for,  as  all 
hysteria,  according  to  them,  is  due  to  a  more  or  less  conscious  simulation, 
it  follows  that  it  is  impossible  to  make  any  diagnosis  between  an 
hysterical  symptom  and  simulation.  The  whole  difference  would  lie  in 
this  fact,  that  simulation  is  voluntary,  conscious,  and  reasoning,  while 
an  hysterical  symptom  is  but  half  voluntary,  semi-conscious,  and  semi- 
reasonable.  This  distinction  is  evidently  subtle  and  would  hardly  serve 
as  a  basis  for  a  differential  diagnosis.  According  to  our  way  of  think- 
ing, although  we  are  convinced  that  suggestion  plays  a  large  rôle  in  the 
production  and  persistence  of  certain  symptoms,  yet  we  are,  neverthe- 
less, persuaded  that  there  are  hysterical  symptoms  which  cannot  be 
simulated.  If  mutism,  deafness,  and  paralysis  may  be  conceived  as 
being  of  a  purely  suggestive  nature,  which  is,  however,  far  from  being 
always  true,  it  seems  to  us  that  it  would  be  very  difficult  to  attribute 
such  symptoms  as  contracture  and  anaesthesia  to  the  same  cause.  The 
strongest  and  most  vigorous  man  would  be  able  to  maintain  only  for  a 
very  short  time  a  contracture  such  as  one  sees  persisting  in  hysterics 
for  weeks,  months,  and  even  years.  The  most  stoical  individual  would 
be  able  perhaps  to  bear  pain  sufficiently  well  to  utter  no  cry,  but  he 
would  never  be  able  to  prevent  his  face  from  showing  some  sign  of 
suffering  and  to  preserve  an  appearance  of  complete  indifference. 


DIAGNOSIS  OF  FUNCTIONAL  MANIFESTATIONS.       211 

It  is  our  opinion  that  all  the  phenomena  which  emotion  and  shock 
are  able  to  create  may  be  recreated  and  maintained  by  hysteria. 

That  is  to  say,  it  is  very  possible  that  the  phenomena  which  are 
simulated  are  those  which  emotion  of  itself  is  not  able  to  produce.  The 
majority  of  the  trophic  symptoms  of  hysteria  which  we  have  elsewhere 
entered  tentatively  among  the  functional  manifestations  are  symptoms 
open  to  simulation. 

For  the  other  symptoms,  such  as  contractures,  anaesthesias,  etc.,  is  it 
possible  to  trace  the  simulation  which  may  evidently  exist?  A  most 
profound  inquiry  on  the  mode  of  producing  functional  fixations,  a  study 
at  first  hand  of  the  symptoms  themselves,  would  seem  to  us  to  permit 
the  solution  of  the  problem  in  the  great  majority  of  cases. 

First  of  all,  the  hysterical  symptoms  which  are  produced  at  the 
same  time  as  the  emotional  shock  without  any  period  of  development, 
and  a  large  number  of  examples  have  been  quoted,  hardly  admit  a 
pathogeny  of  simulation.  But  these  symptoms  are,  as  a  matter  of  fact, 
rare. 

As  a  rule,  the  symptom,  in  order  to  express  itself  in  all  its  fulness, 
needs  some  time  to  develop  completely.  But  this  period  of  development, 
from  the  symptomatic  point  of  view,  has  to  be  absolutely  blank  in  the 
cases  where  emotion  comes  into  play;  but  the  symptom  is  already  out- 
lined through  the  course  of  this  period.  Before  he  becomes  paraplegic, 
for  example,  the  patient  will  not  feel  quite  sure  of  his  limbs.  If  the 
trouble  becomes  progressively  worse,  he  will  at  the  start  have  no  more 
than  a  virtual  hint  of  its  existence.  The  patient  who  describes  to  you 
such  a  progressive  coming  on  of  the  symptoms  is  no  simulator. 

In  the  presence  of  a  symptom  once  established,  the  great  point  in 
diagnosis  seems  to  us  to  rest  in  the  persistence  of  instinctive  acts  in 
the  injured  region  in  the  hysteric,  and  in  the  absence  of  these  acts 
in  the  simulator  who  is  on  his  guard.  The  instinctive  movements  of 
defence  will  persist  in  the  hysteric,  while  they  will  disappear  in  the 
simulator.  In  other  words,  in  created  functional  troubles  the  true 
hysterical  symptom  is  always  less  logical  than  is  the  simulated  symptom. 

But  the  most  important  element  undoubtedly  lies  in  the  mental 
state  with  which  the  patient  regards  his  symptom.  The  true  hysterical 
symptom  does  not  worry  the  patient.  He  manages  to  accommodate 
himself  to  it  in  some  fashion.  With  the  simulator  there  is  nothing  of 
the  sort.  He  always  appears  to  be  extremely  concerned  about  his 
functional  fixations,  and  this  is  one  of  the  commonest  facts  in  those 
whose  symptoms  ** interfere  with  their  work."  Certain  reserves,  how- 
ever, must  be  made.  It  is  true  that  there  exist  certain  morbid  asso- 
ciations called  hysteroneurasthenic  which  belong  chiefly  to  traumatic 
hysteria,  and  in  which  the  patient  takes  considerable  interest  in  his  con- 
dition. But  if  one  examines  these  patients  rather  carefully  when  they 
are  not  simulating,  one  will  find  that  they  are  disturbed  about  every- 
thing except  their  symptom,  considered  in  itself.  They  proclaim  them- 
selves exhausted  and  unable  to  work.    They  see  themselves  reduced  to 


212  STUDY  OF  FUNCTIONAL  MANIFESTATIONS. 

misery.  But  they  will  never  say  that  they  are  afraid  that  they  will 
always  be  paralyzed,  or  have  this  contracture,  or  that  they  will  have 
more  serious  symptoms.  They  are  obsessed  on  the  results  of  the 
symptom,  but  not  on  the  symptom  itself.  The  simulator  behaves  quite 
differently,  for  in  his  case  the  functional  fixation  occupies  the  most 
prominent  place  in  his  mentality. 

Under  some  circumstances,  however,  the  question  of  diagnosis  be- 
comes more  delicate.  It  is,  as  a  matter  of  fact,  by  reason  of  their 
very  mentality  that  certain  hysterics  are  simulators.  But  in  these  cases 
they  are  hysterical  in  character;  they  are  not  cases  where  the  mental 
condition  has  been  unhinged  by  an  emotional  shock,  but  where  it  has 
always  existed.  This  is  no  longer,  properly  speaking,  hysteria;  it  is 
mythomania,  and  there  is  no  doubt  that  a  certain  number  of  patients — 
though  certainly  not  all,  nor  even  the  majority — ought  to  be  struck  out 
from  the  nosological  picture  of  hysteria  and  put  into  that  of  mythomania. 

However  it  may  be,  with  the  sudden  onset  or  distinctly  progressive 
symptoms,  with  the  persistence  of  instinctive  actions  and  with  psychic 
indifference  in  the  presence  of  the  symptom,  it  seems  to  us  that  we  have 
enough  cardinal  characteristics  to  permit  us  to  differentiate  a  true 
hysterical  symptom  from  a  phenomenon  of  simulation. 

As  for  the  diagnosis  between  an  hysterical  symptom  and  an  organic 
symptom,  that  is  nearly  always  very  easy.  It  may  be  necessary,  under 
some  circumstances,  to  employ  laboratory  methods  (lumbar  puncture), 
principally  when  there  is  difficulty  in  walking  ;  but  in  the  great  majority 
of  cases  the  clinical  characteristics  alone  are  sufficient  to  establish  the 
differential  diagnosis,  all  the  more  so  that  for  a  certain  number  of 
years  the  semiology  has  been  enriched  by  so  many  positive  signs  of 
organic  affections  that  it  is  hardly  possible  now  to  make  an  error.  In 
the  hystero-organic  associations  alone  it  may  sometimes  be  a  rather 
delicate  matter  to  distinguish  between  functional  troubles  and  troubles 
with  an  organic  cause. 

There  is,  however,  one  last  test  for  neurasthenic  functional  fixations 
as  well  as  for  hysterical  symptoms.  This  is  the  treatment.  All  func- 
tional symptoms  may  be  cured  by  psychotherapy,  which  naturally  is 
powerless  in  the  presence  of  the  results  of  an  organic  lesion.  This  is  a 
diagnostic  procedure  which  one  should  not  call  in  except  as  a  last  resort, 
after  a  thorough  examination,  in  which  one  has  examined  every  possible 
organic  source  for  the  symptoms  presented. 

For  ourselves,  who  have  a  rather  broad  conception  of  neuropathic 
pathology,  we  consider  it  a  very  bad  mental  attitude,  and  one  even 
more  dangerous  than  that  of  viewing  everything  as  organic,  when  the 
physician  acts  in  the  opposite  way  and  inconsiderately  says  to  his 
patient,  whom  he  is  examining  for  the  first  time  and  who  complains 
of  his  various  troubles,  **This  is  a  case  of  nerves.''  It  is  the  right  and 
duty  of  such  a  man  to  tell  the  patients  this  while  developing  the  thera- 
peutic consequences  of  their  illness,  but  only  when  he  is  sure  that  there 
is  no  organic  trouble. 


SECOND   PART 


Synthetic  Study  of  the  Psychoneuroses  and  Their  Functional 

Manifestations 

The  first  part  of  this  work  has  heen  devoted  to  the  analytical  study 
of  the  phenomena  of  which  patients  complain  when  they  are  afflicted 
with  functional  nervous  troubles.  For  every  one  of  the  objective  or 
subjective  symptoms  with  which  they  may  be  attacked,  we  have  offered 
an  interpretation.  We  have  thus  been  led  to  perceive  how  great  a  rôle 
emotion,  attention,  and  suggestion  have  played  in  the  production  of 
the  sjrmptoms  and  as  incidents  in  the  evolution  of  the  psychoneuroses. 
The  object  of  the  second  part  of  this  work  will  be  to  bring  together 
these  individual  analyses,  into  a  conception  of  the  whole,  to  show  what 
we  think  the  psychoneuroses  are,  the  manner  in  which  they  are  caused, 
and  the  general  mechanism  which  gives  rise  to  particular  symptoms. 

We  wish,  above  all,  to  attempt  to  give  a  distinct  and  precise  con- 
ception of  neurasthenia,  to  isolate  neurasthenia,  with  its  general  char- 
acteristics, from  the  whole  series  of  physical  and  psychic  conditions 
which  are  too  apt  to  be  mistaken  for  it.  It  seems  to  us  that  neuras- 
thenia is  really,  in  spite  of  all  that  has  been  said,  an  independent  psycho- 
neurosis,  connected  perhaps  by  an  intermediary  series  with  other  psycho- 
logical conditions,  but  having  nevertheless  characteristics  which  are  so 
sharp  that  it  may  be  considered  as  a  true  morbid  entity. 

We  shall  pass  a  little  more  rapidly  over  hysteria.  Almost  every- 
body agrees,  concerning  it,  at  least  practically  though  not  theoretically. 
The  comparisons  between  hysterical  and  neurasthenic  manifestations 
cannot  help  but  be  extremely  instructive,  and  it  is  for  this  reason  more 
than  any  other  that  we  shall  devote  a  few  pages  to  a  conception  of  the 
general  picture  of  hysteria  and  of  its  symptoms. 


218 


CHAPTER  XIII. 

NEURASTHENIA  AND  ORGANIC  CONCEPTIONS  CONCERNING  IT. 

Everybody  agrees  that  neurasthenia  is  a  neurosis, — that  is  to  say,  a 
nervous  disease  without  any  known  lesions.  It  is  very  natural  that  there 
should  be  engrafted  upon  this  general  idea  a  great  many  peculiar 
conceptions  in  the  endeavor  to  interpret  the  pathogenic  mechanisms  of 
a  neurasthenic  condition.  By  the  very  nature  of  things,  neurasthenia 
ought  to  pass  through  the  same  phases  which  have  progressively  diverted 
from  the  list  of  the  neuroses  a  certain  number  of  affections  whose  true 
organic  nature  has  been  brought  to  light  by  the  progress  of  science. 

It  is  quite  to  be  expected  that  in  a  period  where  all  medical  progress 
sprang  from  pathological  anatomy  and  from  the  laboratory,  where  one 
was  able  to  see  a  certain  number  of  diseases  which  had  hitherto  not  been 
classified  become  anatomically  and  pathologically  defined,  that  the 
medical  mind  should  rebel  against  the  idea  of  any  disease  without  lesions, 
without  at  least  the  slightest  of  all  lesions,  such  as  represented  by  some 
humoral  change,  a  disturbance  in  secretions,  or  some  reciprocal  effe<ît 
of  the  blood-vessels  upon  the  functions. 

If,  as  all  that  has  gone  before  has  very  clearly  shown,  it  is  our 
conception  that  one  must  take  out  of  the  class  of  neuroses,  those  diseases 
with  indetermined  lesions  but  which  are  not  indeterminable,  the  psycho- 
neuroses  whose  chief  characteristic  is  that  the  trouble  is  purely  psycho- 
logical, we  do  not  feel  that  we  should  be  astonished  at  the  opposition 
which  our  point  of  view  must  receive  from  many  excellent  thinkers. 
As  a  matter  of  fact,  among  all  the  authors  who  have  attempted  to 
interpret  neurasthenia,  by  far  the  greater  majority  of  them  attribute 
this  affection  to  some  organic  trouble.  This,  however,  is  only  a  question 
of  the  mental  attitude,  of  the  times  and  of  methods,  and  one  can  easily 
see  how  neurasthenia  or  '  '  psychoneurosis  "  runs  counter  to  the  most 
legitimate  and  well-established  medical  conceptions  which  have  been 
built  up  in  the  course  of  centuries. 

One  cannot  help  but  be  struck,  at  the  very  start,  by  the  multitude 
of  organic  interpretations  which  have  pretended  to  furnish  a  sufficient 
explanation  of  the  facts  observed.  Neurasthenia  might  be  essentially 
polymorphic  and  multisymptomatic  ;  it  is  none  the  less  curious  to  see 
the  essentially  different  positions  taken  by  the  various  authors  in  their 
pathogenic  conceptions.  Never  perhaps  has  any  disease  lent  itself  to  so 
many  discordant  interpretations. 

We  hold  neither  to  the  genital  theory  nor  to  the  vasomotor  theory. 
The  latter  could  by  no  means  possess  more  than  the  merit  of  inter- 
preting certain  phenomena  presented  by  neurasthenics.  It  retreats  from 
the  problem  without  furnishing  any  solution  of  it.  We  shall  simply 
214 


NEURASTHENIA  AND  ORGANIC  CONCEPTIONS.        215 

mention  the  theories  of  acid  dyscrasia,  of  demineralization,  and  various 
chemical  disturbances  of  nutrition;  we  shall  cite  the  theory  of  neu- 
rasthenia of  hepatic  or  cholemic  origin,  of  neurasthenia  by  visceral 
ptosis,  and  neurasthenia  of  cerebellar  origin.  The  simple  mention 
of  the  thyroid  theories  and  the  theories  attributing  neurasthenia  to  a 
complex  disturbance  in  the  functioning  of  the  blood-vessels  we  feel  is 
enough. 

As  a  matter  of  fact,  two  broad  doctrines  sum  up  almost  completely 
all  the  modem  organic  interpretations  of  neurasthenia, — namely,  the 
theory  of  intoxication  and  the  theory  of  exhaustion.  These  two  theories, 
moreover,  are  not  incompatible,  and,  according  to  certain  authors, 
neurasthenics  may  be  either  suffering  from  exhaustion  or  from  intoxica- 
tion, or  from  both  at  the  same  time. 

The  partisans  of  neurasthenic  disease  by  intoxication  do  not  exploit 
it  any  more  often  than  intoxication  of  endogenous  origin, — ^namely, 
auto-intoxication.  The  facts  upon  which  this  doctrine  seeks  to  found 
itself  are  of  various  kinds.  First  of  all,  there  is  the  frequent  existence 
of  digestive  troubles  in  neurasthenics.  At  the  period  when  the  doc- 
trine of  dilatation  of  the  stomach  was  dominant,  it  was  to  the  latter,  by 
the  intermediary  of  gastric  fermentation  and  secondary  toxic  reab- 
sorption,  that  was  attributed  the  capital  rôle  in  the  production  of 
neurasthenic  conditions.  It  goes  without  saying  that  the  absence  of 
neurasthenic  conditions  in  major  organic  dilatation  of  the  stomach,  as 
well  as  the  frequent  absence  of  any  digestive  disturbance  in  neuras- 
thenics, does  not  permit  us  to  attach  any  serious  importance  to  such  a 
conception.  Similar  theories  based  upon  the  insufficient  elaboration  of 
albuminoid  material  by  vitiated  digestive  functions  are  open  to  the  same 
objections. 

The  modifications  of  the  urine  found  in  neurasthenics  have  served 
as  a  basis  for  a  whole  series  of  diathetic  theories.  The  unfortunate 
thing  is  that  the  variations  observed  are  extremely  inconstant  and  dif- 
ferent between  one  subject  and  another.  The  urines  of  this  neuras- 
thenic are  hyperacid,  of  another  hypoacid.  The  urine  is  sometimes 
scanty  and  sometimes  increased,  as  is  also  the  uric  acid.  The  urinary 
relations  undergo  every  possible  variety.  The  accidental  and  rare  pres- 
ence, however,  of  pathological  products  in  the  urine,  such  as  sugar, 
urobilin,  indican,  and  the  various  albumins,  is  nothing  but  an  epi- 
phenomenon,  without  any  pathological  relations  to  the  neurasthenic 
condition  which  is  in  progress.  Briefly,  there  is  no  urology  of 
neurasthenia. 

Arterial  tension  has  also  been  invoked.  But  this  again  is  so  variable 
that  the  very  authors  who  have  attached  a  certain  importance  to  it 
have  been  obliged  to  divide  neurasthenics  into  two  classes, — those  with 
hypertension  who  would  be  suffering  from  intoxication,  and  those  with 
hypotension  who  would  be  suffering  from  exhaustion.     They  fail  to 


216     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

mention  the  existence  of  an  intermediary  class  which  is  by  far  the 
most  numerous,  that  of  neurasthenics  whose  tension  is  normal. 

Does  there  exist  any  positive  sign  whatsoever  of  an  auto-intoxication 
to  which  neurasthenic  conditions  might  be  attributed?  To  tell  the 
truth,  there  does  not  seem  to  be  any  single  one  which  will  apply  to  a 
sufficient  number  of  patients  for  any  theory  whatsoever  of  neurasthenia 
by  auto-intoxication  to  be  founded  upon.  And  it  is  really  too  simple 
a  supposition  to  suppose  or  admit,  as  some  have  done,  a  multiple 
pathogeny  in  the  absence  of  any  definite  pathogeny.  Neurasthenia,  cer- 
tain authors  practically  say,  is  a  syndrome  having  its  source  in  the 
most  diverse  auto-intoxications  and  manifesting  itself  inherently  by  a 
great  variety  of  phenomena. 

Would  it  not  be  much  better  to  acknowledge  frankly  that  any 
theory  of  auto-intoxication  in  neurasthenia  cannot  at  the  present  time 
be  maintained  with  any  show  of  truth?  One  might  just  as  well  try  to 
uphold  the  toxic  origin  of  hysteria.  Some  authors,  it  is  true,  have 
thought  of  this,  but  very  few  have  lingered  long  in  the  way.  And, 
as  far  as  neurasthenia  is  concerned,  they  have  very  poorly  grasped  the 
reasons  why  physicians  have  set  themselves  against  establishing  a 
pathogenic  path  which  does  not  seem  to  lead  anywhere. 

The  theory  of  exhaustion  becomes  confused  in  a  certain  degree  with 
the  theory  of  auto-intoxication.  But  here  it  is  a  question  of  a  very 
special  auto-intoxication,  of  an  auto-intoxication  caused  directly  by 
overwork  and  by  the  waste  products  of  this  assimilation  which  have 
been  produced -in  excess. 

By  the  partisans  of  this  theory,  neurasthenia  is  an  exhaustion  of 
the  nervous  system,  just  as  the  individual  who  has  made  any  very  con- 
siderable physical  effort  has  exhausted  his  muscular  system,  and  is  in 
need  of  rest  before  he  is  able  to  take  up  his  work  again. 

But  the  great  difference  between  the  neurasthenic  and  the  person 
who  is  fatigued  or  exhausted  is  that  the  latter  will  spontaneously  recover 
his  energy  after  he  has  had  a  chance  to  rest,  while  the  neurasthenic  will 
not  recover  it.  At  least  it  will  take  considerably  more  time  for  the 
latter  patient.  The  nervous  system  being  exhausted,  there  will  be  a 
very  low  state  of  functional  activity  of  all  the  organs,  which  will  be 
expressed  in  a  feeling  which  will  penetrate  the  consciousness  and  even 
affect  the  mind  of  the  patient.  In  this  way  the  mental  condition  of 
the  neurasthenic  is  created. 

This  theory,  which  does  not  explain  much,  and  which  is  nevertheless 
much  more  etiological  than  pathogenic,  has  at  least  the  merit  of  being 
based  on  a  certain  number  of  clinical  facts. 

First  of  all,  in  the  etiology  of  neurasthenia,  it  is  the  rôle  of  physical, 
intellectual,  or  moral  overwork  which  has  probably  been  the  important 
starting-point  of  this  conception.  Now,  this  rôle  seems  to  us  doubtful, 
at  least.  Overwork  in  itself  has  never  created  neurasthenic  conditions, 
and  we  shall  learn  further  on  to  distinguish  between  the  conditions  of 


NEURASTHENIA  AND  ORGANIC  CONCEPTIONS.        217 

fatigue  which  overwork  really  brings  on  and  neurasthenic  conditions^ 
which  follow  only  under  very  special  circumstances. 

This  is  because  when  one  is  overworked  there  is  generally  some  special 
reason  for  it.  Those  people  who  are  always  rushing  themselves  to  death  for 
no  reason  and  without  any  aim  or  object  are  already  virtual  neurasthenics, 
having  an  antecedent  psychological  trouble  which  existed  before  their 
overwork,  properly  so  called.  Those,  on  the  other  hand,  to  whom  such 
overwork  is  a  means  to  neurasthenia,  and  it  is  the  general  rule,  constantly 
add  to  their  intellectual  and  physical  work  all  kinds  of  preoccupations.  As 
one  of  us  had  already  written  in  1886,  "It  is  brain  work  doubled  by 
worry  and  anxiety  which  creates  neurasthenia."  In  one  case  it  may  be 
the  future  which  comes  into  play.  There  it  is  one's  amour  propre.  In 
another  case  it  is  the  family  fortunes,  the  bread  for  one's  children, 
that  one  is  striving  for.  There  is  always  added  to  overwork  such 
psychological  elements  of  preoccupation. 

We  shall  see  a  little  further  on  that  it  is  some  such  element,  and  not 
the  overwork  in  itself,  which  creates  neurasthenia.  As  a  matter  of  fact, 
to  speak  only  of  physical  overwork,  one  has  but  to  question  army 
physicians  to  be  convinced  of  the  reality  of  what  we  are  setting  forth. 
During  manœuvres  or  wars,  whatever  may  be  the  fatigue  imposed,  not 
only  upon  young  soldiers,  but  also  on  the  reserves  and  the  volunteers, 
one  never  sees  any  neurasthenia, — ^that  is,  according  to  the  idea  of 
fatigue  conditions  which  cannot  easily  be  repaired,  or  states  of  true 
exhaustion.  On  the  other  hand,  one  frequently  sees  men  who  are  com- 
pletely used  up,  who  require  a  rest  of  several  hours,  or  perhaps  of 
several  days,  to  put  them  on  their  feet  again. 

We  do  not  believe,  moreover,  that  we  could  cite  one  case — ^not  a 
single  case,  we  repeat — of  a  neurasthenic  condition  coming  on  as  the 
result  of  tranquil  intellectual  work  wholly  free  from  anxiety.  The 
overworked  accountant  only  becomes  neurasthenic  through  fear  of  losing 
his  place.  In  the  whole  list  of  men  who  accomplish  great  intellectual 
work,  neurasthenia  is  extremely  rare  if  only  it  is  unaccompanied  by  any 
of  those  various  elements  which  start  up  psychological  disturbances  of 
any  kind. 

The  fact — forming  another  element  of  the  theory,  and  which  cannot 
be  contested, — ^namely,  that  there  are  neurasthenics  who  are  really 
exhausted, — cannot  be  denied.  In  other  terms,  there  are  people  suffer- 
ing from  fatigue  in  whom  no  amount  of  rest  in  proper  proportion  to 
the  fatigue  is  enough-to  put  them  on  their  way;  this  cannot  be  denied. 
There  are  a  great  number  of  such  patients.  But  we  must  make  this 
clear.  In  such  cases  we  do  not  have  neurasthenics  simply  to  deal  with  ; 
we  find  ourselves  in  the  presence  of  patients  in  whom  the  exhaustion 
is  a  secondary  phenomenon  connected  with  the  first  stages  of  mental 
anorexia  to  which  so  many  of  these  patients  are  susceptible. 

It  is  very  true  that  a  rest  of  a  week,  a  fortnight,  a  month,  would 
not  be  enough  to  give  back  strength  to  a  patient  who  for  weeks,  months^ 


218     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

or  years  had  not  taken  sufficient  nourishment,  and  who  had  practised, 
from  a  moral  and  intellectual  as  well  as  a  physical  point  of  view,  the 
most  deplorable  hygiene.  These  are  the  patients  whom  we  have  already 
described  as  neurasthenics  who  have  ''arrived."  Their  history  is  of 
no  value  in  building  up  a  pathogenic  theory  of  neurasthenia,  because 
the  structure  here  is  too  complex.  In  order  to  understand  neurasthenia 
one  must  apply  one's  self  to  the  beginning  of  the  neuropathic  condition, 
when  the  patient  was  still  free  from  any  superadded  trouble. 

Again  we  must  not  let  ourselves  be  deceived,  for  in  the  very  ex- 
haustion of  these  ''arrived"  neurasthenics  the  psychic  factors  perhaps 
play  a  much  larger  rôle  than  has  been  thought,  and  one  much  more 
important  at  all  events  than  the  upholders  of  the  organic  theory  have 
proposed.  We  will  not  dwell  upon  this,  but  merely  refer  the  reader  to 
what  we  have  written  concerning  the  asthenia  of  neuropaths. 

To  sum  up,  the  theory  of  exhaustion,  with  or  without  secondary 
intoxication,  does  not  correspond  to  the  reality  of  clinical  facts  any 
more  than  the  theory  of  the  primary  disturbance  by  intoxication. 

We  hold  that  neurasthenia  is  due  wholly  to  psychological  factors, 
and  that  these  psychological  factors  are  essentially,  if  not  exclusively, 
determined  by  emotion.  It  is  to  this  thesis  that  we  will  devote  the 
following  chaoier.* 


CHAPTER  XIV. 

THE    RÔLE   OF   EMOTION    AND   EMOTIONALISM   IN   THE   GENESIS   OP   THE 

PSYCHONEUROSES. 

In  the  first  part  of  this  work  we  have  frequently  brought  out  the 
important  rôle  which  is  played  by  the  emotions  in  the  production  of  the 
functional  symptoms  of  neuropaths.  We  have  seen  that  a  great  many 
of  them  might  be  considered  as  the  crystallizations  of  emotional  phenom- 
ena. We  would  like  now  to  push  our  study  a  little  further,  and  to  draw 
from  the  facts  that  we  have  already  set  forth  the  conclusions  to  be 
^  derived  from  them,  and  to  show  also  in  what  degree  emotion  may  be 
responsible  for  the  establishment  not  only  of  the  sjrmptoms  of  the 
psychoneuroses  but  for  the  very  genesis  of  the  mental  condition  on 
which  these  symptoms  are  engrafted. 

But  first  of  all  we  must  get  a  little  more  precise  conception  of 
emotion.  Just  how  far  does  it  extend?  What  are  the  phenomena 
which  enter  into  its  make-up?  To  what  mental  and  physical  reactions 
does  it  lead?  What  is  emotionalism,  under  what  influences  is  it 
developed,  and  to  what  does  it  respond?  You  see  how  many  problems 
there  are,  and  how  singularly  complex,  which  we  must  attempt,  not  to 
solve,  but  at  least  to  explain. 

First  of  all,  so  far  as  the  production  of  emotional  stimuli  is  con- 
cerned, it  seems  to  us  that  a  very  important  division  ought  to  be  made. 
Emotion  may,  in  fact,  be  of  external  or  of  internal  origin. 

Emotional  Stimuli  of  External  Origin.  Emotional  Shock. — 
A  person  may  be  caught  in  a  railway  accident,  or  be  abruptly  told  of 
the  death  of  a  relative,  or  find  himself  suddenly  ruined;  these  are 
examples,  taken  at  random,  of  a  whole  series  of  external  emotional 
stimuli,  creating  what  we  have  called  emotional  shock, — ^that  is  to  #y, 
a  sudden  intense  emotion,  coming  on  without  any  preparation  to  a 
subject  who  is  perfectly  tranquil  in  mind.  But  an  emotional  shock  does 
not  belong  only  to  the  negative  events  of  life.  A  great  joy,  the  un- 
expected success  of  some  plan  which  is  dear  to  one,  a  fortune  which 
one  had  not  dreamed  of  falling  into  one's  hands,  may  in  the  same  way 
constitute  an  emotional  shock.  The  common  factor  in  these  phenomena 
is,  therefore,  making  the  subject  pass  by  a  shock  or  surprise  from  one 
moral,  material,  or  affective  situation  into  another  wholly  different  one, 
for  which  he  is  insufiiciently  prepared  and  to  which  his  present  men- 
tality is  by  no  means  adapted. 

One  must  not  imagine,  however,  that  external  emotional  actions  are 
limited  to  the  great  shocks  of  life.  Between  a  great  emotional  shock  and 
a  slight  emotional  stimulus  there  is  every  shade  of  intermediary  grada- 

219 


220     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

tion.  If  one  takes  this  fact  into  consideration  that  there  is  no  necessary- 
relationship  between  the  intrinsic  gravity  of  the  emotional  stimulus  and 
the  reaction  which  constitutes  the  emotion,  one  can  immediately  see 
how  much  interest  there  may  be  in  recognizing  in  a  patient  the  ex- 
istence of  emotional  stimuli  which  although  sometimes  very  slight  in 
themselves  yet  may  cause  considerable  reaction. 

Will  he  be  indifferent  to  this  disagreeable  surprise,  or  that  little 
unexpected  event?  Some  slight  wound  to  his  feelings  or  to  his  self- 
conceit,  the  bringing  into  play  of  certain  sides  of  his  personality  which 
sometimes  are  considerably  exaggerated  and  wholly  out  of  proportion, — • 
all  these  are  so  many  trifling  causes  which  may  call  forth  slight  or  even 
great  emotions.  On  the  other  hand,  emotional  reaction,  but  of  a 
peculiar  order,  may  be  brought  about  by  certain  stimuli,  such  as  a 
keen  artistic  impression,  the  discovery  of  a  wonderful  view,  something 
moving  that  one  has  read,  or  some  slight  triumph  obtained  either  by 
one's  self  or  one  of  the  family. 

Speaking  generally,  there  are  two  kinds  of  phenomena  in  life.  On 
the  one  hand  there  are  those  which  are  regulated,  foreseen,  and  ex- 
pected, to  which  one  is  adequate  and  for  which  one 's  life  is  adapted  ;  on 
the  other  hand  there  are  those  which  one  does  not  expect,  which  sur- 
prise, astonish,  and  jar  one.  The  former  never  produce  emotional 
reactions,  while  the  latter  are  always  likely  to  provoke  them.  It  is  no 
longer  a  question  of  stimulus;  it  is  the  circumstances  under  which  the 
emotional  action  is  exercised  which  comes  into  play,  with  all  variations. 
As  we  shall  see  further  on,  in  order  to  create  the  same  reaction,  the 
intrinsic  value  of  the  emotional  action,  on  the  one  hand,  and  the  emotion- 
alism of  the  subject,  on  the  other,  are  two  factors  which  vary  in  an 
inverse  relation  one  to  the  other. 

Emotional  Stimuli  of  Internal  Origin. — Emotion  has  not  neces- 
sarily any  external  cause.  We  would  readily  say  that,  as  far  as 
numbers  are  concerned,  if  not  intensity,  emotional  stimuli  of  internal 
origin  play  a  preponderate  rôle.  Sometimes  it  will  be  the  recollection 
or  the  memory  of  a  previous  emotional  shock,  which  will  be  the  starting- 
point  of  the  emotional  reaction.  Is  it  not  a  common  thing  to  hear  a 
person  say  that  he  cannot  recall  a  certain  thing  without  being  affected 
by  it?  But  it  is  not  even  necessary  that  one  should  have  previously 
experienced  an  emotional  shock.  One  can  become  emotional  over  a 
simple  idea  which  knocks  at  the' threshold  of  consciousness.  Think  of 
the  death  of  some  one  who  is  very  dear  to  you,  or  that  ruin  is  lying  in 
wait  for  you,  or  of  some  possible  dishonor,  or  of  a  threatening  illness, 
and  without  these  thoughts  having  any  objective  foundation  whatsoever 
they  will  be  enough  to  create  emotional  reactions. 

As  a  matter  of  fact,  it  is  very  difficult  to  separate  exactly  what 
belongs  to  interior  emotion  from  what  is  likely  to  be  created  there. 
What  difference  is  there  between  a  sentimental  state  and  an  emotional 
state  ?    The  emotion  is  certainly  not  very  sharp.    The  religious  emotioa 


THE  RÔLE  OF  EMOTION  AND  EMOTIONALISM.         221 

•of  the  person  who  prays,  the  aesthetic  emotion  of  the  artist  who  creates, 
the  intellectual  emotion,  if  we  might  so  call  it,  of  the  thinker  who  evolves 
something,  are  all  emotional  phenomena,  but  which  are  singularly  re- 
mote from  internal  emotional  shock.  Even  a  dream  might  in  some  cases, 
if  it  introduced  sufficiently  vivid  pictures  into  consciousness,  be  regarded 
as  an  emotional  stimulus. 

We  would  readily  go  still  further,  for  we  hold  that  all  manifesta- 
tions of  individual  psychological  activity  which  do  not  belong  to  the 
domain  of  pure  consciousness  may,  after  all,  appear  as  touching  the 
domain  of  emotional  stimuli.  The  idea  itself  only  draws  its  creative 
value,  its  force  of  action,  from  the  emotional  reinforcement  which  it 
may  undergo,  and  from  the  fact  that  it  may  be  attached  in  some  way 
to  some  intimate,  profound,  unconscious  or  unreasoning  phase  of  our 
personality. 

In  a  very  general  way,  emotion  is  a  reaction  of  the  personality.  It 
is  called  sthenic  when  the  emotional  excitation  acts  in  the  sense  of 
development  of  the  personality.  It  is  called  depressing  when,  on  the 
other  hand,  this  stimulus  arrests  or  reduces  the  action  of  the  personality. 

What  are  now  the  psychological  modifications  produced  by  emotional 
stimuli?  These  modifications  are  evidently  variable  according  to  the 
nature  and  intensity  of  the  stimulus.  They  vary  still  further  according 
as  to  whether  they  are  regarded  as  immediate  or  as  later  results  of  it. 

Immediate  Psychological  Modifications  Produced  by  Emotional 
Stimuli. — Emotion  may  completely  overthrow  the  equilibrium  of  the 
subject  who  experiences  it.  Under  the  influence  of  an  emotion  he  will 
become  incapable  of  any  conscious  action  or  judgment.  He  will  act 
like  a  crazy  man.  This  is  the  peculiar  quality  of  intense  emotional 
shock,  which  can  suddenly  completely  overwhelm,  as  it  were,  individual 
consciousness.  Deprived  of  his  most  elementary  perceptions,  feeling 
nothing,  seeing  nothing  and  hearing  nothing,  the  subject  is  transformed 
into  a  simple  automaton,  and  is  plunged,  as  it  were,  into  a  state  of 
psychologic  syncope. 

Although  this  modification  may  in  a  few  rare  instances  be  lasting, 
and  the  psychic  disorientation  which  follows  the  emotion  may  become 
fixed  in  the  form  of  some  characteristic  mental  affection,  more  often 
this  does  not  occur,  and  the  syncope  is  followed  by  a  gradual  coming 
back  to  one 's  self.  But  the  regaining  of  conscious  judgment  is  far  from 
being  regular.  It  is  attained  only  after  successive  relapses.  The  sub- 
ject at  first  manages  to  get  hold  of  himself  for  a  few  moments,  then  his 
emotion  sweeps  over  him  again.  He  thus  passes  through  successive 
waves  of  emotion.  Although  the  moments  of  conscious  self-control  will 
in  the  majority  of  cases  lengthen,  and  finally  the  time  will  come  when 
the  individual  has  regained  complete  mastery  over  himself,  yet  this  does 
not  always  come  to  pass,  and  it  may  happen  that  for  weeks,  months, 
and  even  years,  the  same  succession  of  moments  of  self-control  and 
periods  of  emotion  will  continue  to  be  produced.     This  is  when  the 


222     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

emotion  is  continually  being  renewed  by  the  mechanism  of  memory. 
But  independent  even  of  memory,  this  series  of  oscillations,  which  tend 
toward  equilibrium,  may  be  prolonged  for  a  very  long  time. 

It  would  not  be  exact  to  say  that  emotional  excitement  always 
produces  this  immediate  and  sudden  upsetting  of  conscious  control.  It 
sometimes  happens  that  even  the  most  profound  emotion  requires  a 
certain  amount  of  time  to  produce  this  result.  It  would  seem  as 
though  to  gain  its  full  effect  the  emotional  stimulus  needs  to  be  re- 
inforced by  the  addition  of  internal  emotion,  and  that  the  external 
stimulus  grows,  as  it  were,  like  a  rolling  snowball,  to  greater  propor- 
tions by  contact  with  internal  emotions. 

The  action  of  slight  emotional  shocks — that  is  to  say,  of  emotional 
excitations  of  comparatively  slight  importance,  coming  from  outside — 
varies  from  one  subject  to  another.  There  are  some  people  who  behave 
in  the  same  way  over  emotions  which  are  trifling  in  themselves  as  they 
would  behave  under  one  of  the  most  serious  shocks  of  their  existence. 
The  quality  of  the  emotion  comes  in  here,  in  a  peculiar  way,  and  each 
individual  has  his  realm  of  special  susceptibility.  Here,  again,  the 
emotional  shock  does  not  assume  its  full  importance  until,  after  being 
reinforced  by  interior  emotion,  it  has  sounded,  under  the  emotional  in- 
fluence, the  more  or  less  profound  depths  of  personal  individuality. 
The  latter  will  react  sharply  to  an  emotional  shock  which  even  lightly 
touches  the  affective  domain,  and  will  not  react  at  all,  or  very  slightly, 
if  attacked  from  the  point  of  view  of  material  things  or  ambitions.  The 
importance  of  the  personal  coefficient  increases  in  direct  proportion  as 
the  intrinsic  importance  of  the  emotional  shock  decreases. 

External  emotions,  even  the  most  trifling,  may  produce  considerable 
effect,  perhaps  less  upon  the  intellectual  function  properly  so  called 
than  on  the  morale.  It  constantly  happens  that  under  emotional  action 
a  person's  mentality  will  completely  veer  about.  All  of  us  in  differing 
degrees  are  more  or  less  susceptible  to  alternate  moods,  passing  rapidly 
from  more  or  less  pronounced  states  of  depression  to  more  or  less 
marked  excitement.  Without  any  transition,  these  emotional  excitations 
may  make  us  pass  from  one  condition  to  another,  and  this  is  just  as 
true  for  slight  emotional  surprises  that  are  positive  as  for  those  of  a 
negative  nature.  It  is  quite  frequent  to  find  that  some  unexpected 
pleasure  will  make  us  sad  and  pessimistic.  This  fact,  moreover,  has 
much  more  therapeutic  than  pathogenic  value  in  the  history  of  the 
psychoneuroses. 

In  a  general  way,  all  the  little  depressing  emotions  are  translated 
into  that  peculiar  moral  condition  in  which  we  are  aware  of  various  sen- 
sations of  insecurity  or  more  or  less  marked  anxiety, — the  so-called 
feelings  of  incompleteness,  to  use  Janet's  expression.  It  would  seem 
that  when  one  has  experienced  one  emotional  shock,  one  is  always  ex- 
pecting another.    As  we  shall  see  further  on,  emotion  begets  emotionalism. 

As  for  the  immediate  psychological  effect  produced  by  those  emotions 


THE  EÔLE  OF  EMOTION  AND  EMOTIONALISM.         223 

which  we  have  described  as  internal,  it  does  not  differ  from  that  which 
is  produced  by  the  emotions  of  external  origin.  The  essential  thing 
which  distinguishes  an  external  emotion  from  an  internal  emotion, 
though  the  latter  may  sometimes  be  a  residue  of  the  former,  is  chiefly 
the  lesser  continuity  of  action.  As  a  matter  of  fact,  the  internal  emotion 
being  closely  allied  with  the  mentality  of  the  subject  and  secondary  to 
it,  it  naturally  has  every  chance  to  be  reproduced,  and  reinforced  by 
itself,  with  great  frequency.  The  internal  emotion  created  in  fact  by 
unintermitting  emotional  conditions,  whose  action  becoming  dissolved 
in  the  mentality,  instead  of  being  abrupt  as  in  'an  emotional  shock, 
cannot  help,  in  the  long  run  after  being  subjected  to  a  whole  series  of 
added  phenomena,  but  become  finally  established. 

After  having  seen  what  are  the  immediate  psychological  actions, 
we  would  like  to  continue  this  discussion  by  inquiring  into  the  later 
psychological  actions  exercised  by  the  emotions. 

Later  Psychological  Actions  Exercised  by  the  Emotions. 
Preoccupations. — ^In  the  domain  of  pure  consciousness,  the  acquisitions 
of  the  mind  pass  through  a  certain  number  of  stages.  There  is  the 
stage  of  reception,  the  stage  of  judgment,  or,  if  one  so  prefers  it,  the 
adaptation  of  our  mind  to  the  new  idea  introduced,  or  that  phase  of 
acquisition,  properly  so  called,  where  the  idea  becomes  an  integral  part 
of  our  psychic  personahty.  It  is  a  peculiar  characteristic  of  emotional 
actions  that  they  cannot  be  judged.  This  is  because,  as  a  matter  of  fact, 
they  differ  essentially  from  phenomena  of  pure  consciousness.  They 
run  counter  not  only  to  our  intellectuality,  but  to  our  intimate  per- 
sonality and  our  deepest  feelings.  They  act  upon  domains  which  in- 
clude such  profound  ideas  as  the  vital  instinct  and  our  affective  tend- 
encies, for  example.  It  is  impossible  to  introduce  emotional  phenomena 
into  consciousness.  One  cannot — or  it  is  with  great  difficulty  that  one 
can — bring  one 's  self  to  embrace  the  idea  of  illness  or  of  one 's  near 
death,  of  the  idea  of  danger  or  of  ruin,  or  of  the  death  of  some  one 
we  love.  Let  us  put  it  in  other  words — ^which  have  already  become 
classic — one  does  not  adapt  one's  self  to  emotional  ideas,  because  they 
strike  at  the  very  foundation  of  things,  at  the  entity  of  our  being.  The 
intelligence  does  not  adapt  itself  any  better  to  ideas  which  hurl  them- 
selves against  the  make-up  of  one's  consciousness.  An  emotion  which 
is  judged  and  which  has  become  an  integral  part  of  acquired  conscious- 
ness is  by  this  very  fact  no  longer  an  emotion. 

If  the  emotional  upsetting  of  our  intimate  personality  may  be  ex- 
pressed by  violent  reactions,  such  as  anger  or  sudden  impulse,  will 
it  not  at  least  show  itself  by  the  persistence  of  the  emotional  idea  in 
consciousness?  However  much  we  may  mentally  revolt  against  an 
emotional  idea,  it  will  nevertheless  remain  to  form  a  mental  state  which 
we  then  call  a  preoccupation.  Here  we  enter  into  the  very  mechanism 
of  the  genesis  of  psychoneuroses,  and  can  conceive  how  important  a 
rôle  is  played  by  the  emotional  factor  of  preoccupation. 


224     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

But  emotion  acts  in  still  a  different  way,  and  precisely  because  it 
makes  those  subjects  who  are  its  plaything  lose  their  faculties  of  judg- 
ment and  intellectual  control.  The  moment  that  a  conflict  is  set  up  in 
us  between  our  intimate  feelings  and  actions  of  an  exterior  or  interior 
origin,  our  intelligence  loses  the  upper  hand.  Every  individual  in  an 
emotional  condition  becomes  by  this  very  fact  auto-  and  hetero-sug- 
gestible,  because  suggestibility  consists  in  the  possibility  of  the  ad- 
mission into  consciousness,  of  ideas  and  notions  which  are  not  under 
the  control  of  one's  reason.  It  is  by  this  mechanism  that  emotion 
again  plays  the  most  important  rôle  in  the  history  of  the  psycho- 
neuroses. 

What  has  gone  before  enables  us  to  understand  the  exciting  and 
stimulating  action  of  certain  emotional  excitations.  These  are  those 
which  adapt  themselves  easily  to  our  inner  feelings,  strengthen  them, 
and  which  instead  of  diminishing  our  personality  rather  increase  it. 
We  shall  take  up  these  emotions  again  a  little  further  on,  and  shall 
place  a  great  deal  of  importance  upon  them  when  we  come  to  discuss 
the  treatment  of  the  psychoneuroses.  For  the  present  moment  we  only 
ask  you  to  bear  them  in  mind. 

Let  us  remember  as  the  most  important  thing  this  fact,  that,  out- 
side of  emotional  shocks,  which  throw  one  off  one's  balance  for  the 
moment,  one  might  say  that  the  field  of  emotion  occupies  nearly  the 
whole  realm  of  human  life.  Let  us  remember  also  that  among  the 
emotions  there  are  some  which  adapt  themselves  to  our  inner  feelings, 
and  that  there  are  others  more  or  less  violently  opposed  to  them.  It  is 
these  latter  which  as  factors  of  preoccupation  and  suggestibility  dominate 
the  pathogeny  of  the  psychoneuroses. 

Physical  Phenomena  Produced  by  Emotion.  Anguish  and 
Hysterical  Attacks. — ^We  have  now  come  to  the  physical  phenomena 
produced  by  emotional  excitations.  These  phenomena  are  innumerable, 
and  produce  as  passing  phases  nearly  all  the  manifestations  which  when 
prolonged  and  established  constitute  the  majority  of  the  functional 
troubles  which  we  have  studied  in  the  first  part  of  this  book.  However, 
we  shall  not  dwell  here  either  upon  digestive,  cardiac,  or  respiratory 
troubles,  nor  upon  motor  or  sensory  inhibitions,  nor  on  the  vasomotor 
actions  or  secretions  which,  either  directly  and  immediately  or  after 
being  worked  up  for  a  more  or  less  prolonged  period,  may  be  created 
by  the  emotions. 

But  there  are  still  two  other  troubles  which  are  very  important 
in  relation  to  their  cause  and  effect  upon  emotional  stimuli  which  we 
have  not  yet  taken  up.  There  are,  on  the  one  hand,  the  symptoms  of 
anguish,  and,  on  the  other,  the  phenomena  of  hysterical  attacks. 

Anguish  is  a  physical  feeling  which  corresponds  to  the  psychic 
feeling  of  anxiety.  It  sometimes  consists  of  bodily  sensations  of 
thoracic  constriction,  with  the  sensation  of  smothering,  sometimes  by 


THE  RÔLE  OF  EMOTION  AND  EMOTIONALISM.         225 

feelings  of  dull,  deep-seated,  boring  or  stabbing  pain,  which  is  very  fre- 
quently localized  at  the  pit  of  the  stomach,  and  which  may  become 
crystallized  in  the  form  of  nervous  pain. 

Anguish  is  much  less  frequently  created  by  emotional  shock  than 
by  progressive  internal  emotional  stimuli.  It  is  a  physical  diffusion 
of  the  psychic  emotion,  which  is  gradually  amplified  in  consciousness, 
and  which  psychically  creates  the  anxiety  with  which  anguish  is  often 
bound  up. 

Let  us  take,  for  example,  an  idea  of  ruin,  or  death,  or  dishonor, 
which  might  involuntarily  pass  through  our  minds.  This  idea  may 
merely  flit  through  one's  brain,  producing  a  simple  disagreeable  im- 
pression. But  in  certain  subjects,  if  we  may  use  the  expression,  the 
idea  is  going  to  hang  on  to  them,  and  remain  in  a  condition  of  progres- 
sive preoccupation,  which  soon  becomes  anxiety.  When  consciousness 
has  been  completely  invaded  by  this  idea,  and  when  the  individual 
has  lost,  as  it  were,  all  cerebral  control,  he  finds  himself  in  the  grip  of 
the  idea,  as  he  will  find  himself  seized  by  its  realization,  and  this  is 
where  physical  anguish  is  born.  Under  such  circumstances  it  is  nothing 
more  than  a  physical  expression  of  psychic  anxiety.  An  emotion  which 
one  is  dreading,  and  for  which  one  feels  one's  self  more  and  more  un- 
prepared, creates  anguish  by  an  analogous  mechanism.  As  for  emotional 
shock,  it  hardly  ever  creates  the  feeling  of  anguish  until  much  later, 
when  the  subject  recalls  the  emotional  phases  through  which  he  has 
passed,  and  when  he  lives  over  again  the  distressing  moments  which  he 
has  formerly  experienced. 

On  the  other  hand,  feelings  of  anguish  may  become  fixed  in  the 
form  of  a  more  or  less  continual  memory,  or  memories  which  are  more 
or  less  frequently  recalled.  The  memory  of  anguish  recreates  anguish, 
because  the  agonizing  impressions  are  so  painful  that  merely  to  recall 
them  brings  back  the  anxious  emotion,  and  because  also,  under  certain 
circumstances  and  with  certain  individuals,  the  remembrance,  from  the 
point  of  view  of  subjective  impression,  is  equivalent  to  the  thing  itself. 
These  are  the  phenomena  which  we  have  already  seen  when  we  studied 
nervous  pains.  Phenomena  of  anguish,  in  whatever  way  they  may  be 
interpreted,  may  become  the  starting-point  of  a  whole  series  of  secondary 
functional   manifestations,    gastric,   respiratory,    intestinal,   etc. 

We  cannot  expatiate  at  any  length  upon  hysterical  attacks.  Attacks 
with  regular  phases,  such  as  they  used  to  have  at  the  Salpêtrière  in  the 
great  days  of  educated  hysteria,  are  no  longer  to  be  seen  in  our  time. 
But  what  always  exist  are  nervous  attacks  with  emotional  discharge, 
of  every  degree  and  aspect.  They  are  made  up  of  elements  of  various 
orders  which  may  or  may  not  be  associated  with  it,  elements  of  anguish, 
elements  of  motor  agitation  with  tonic  or  clonic  convulsions,  spasmodic 
attacks  of  laughing  or  weeping,  dyspnœa,  and  syncopal  elements  with 
more  or  less  complete  loss  of  consciousness.  In  the  majority  of  cases 
15 


226  SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

the  attack  starts  off  with  feelings  of  anguish,  followed  by  symptoms  of 
syncope,  and  ends  up  with  various  forms  of  motor  agitation. 

When  relieved  of  all  the  elements  which  are  superadded  and  due  to 
cultivation,  such  as  passional  attitudes,  etc.,  an  hysterical  attack  is  by 
no  means  a  phenomenon  of  suggestion  or  simulation.  It  is  directly 
bound  up  with  emotion,  and  often  comes  to  subjects  who  have  never 
known  what  it  was  to  have  a  nervous  attack,  who  have  never  seen 
one,  and  who  once  the  emotional  shock  has  passed  will  never  have 
another  in  the  course  of  their  entire  life. 

An  hysterical  attack  more  usually  occurs  after  an  emotional  shock, 
but  not  always  as  an  absolutely  immediate  result.  It  sometimes  takes 
time  for  the  emotion  to  develop  to  a  sufficient  intensity,  or,  as  we  have 
already  said,  it  requires  a  greater  or  less  length  of  time  to  come  to  a 
head,  and  the  attack  could  not  occur  until  the  emotion  which  was  in 
progress  had  reached  its  highest  point  of  intensity.  It  is  a  gross 
psychological  error  to  think  that  there  is  always  a  direct  relationship 
between  the  emotional  cause  and  the  individual  emotional  reaction.  A 
fact,  as  a  cause  of  emotion,  may  first  of  all  be  accepted  perhaps  by  the 
subject  as  a  simple  matter  of  knowledge  only  to  become  later  a  causal 
fact  of  emotion.  There  is  a  primitive  adaptation  to  the  fact  in  itself, 
but  as  its  recognition  grows  deeper  and  it  affects  one's  inner  feelings 
it  becomes  a  factor  of  emotion.  We  could  cite  numerous  cases  of  this 
kind.  We  have  seen  individuals,  who  were  overcome  by  domestic 
troubles,  caught  in  an  accident  and  not  reacting  at  all  to  the  emotional 
shock  until  a  very  long  time  afterward.  If  you  want  an  example  here 
is  one,  of  a  man  sixty-five  years  of  age,  an  old  soldier  who  had  been  in 
many  campaigns,  decorated  on  the  battlefield  in  1870,  and  who  had 
many  times  been  in  great  danger  without  having  felt  the  slightest 
emotional  phenomenon.  On  his  return  to  civil  life  his  occupation  took 
him  upon  a  dredger.  He  was  accidentally  caught  by  the  machinery  of 
the  dredge,  which  was  stopped  just  in  time  to  save  him  from  being 
crushed.  As  a  matter  of  fact,  he  escaped  from  his  accident  without 
being  hurt  at  all,  and  was  only  slightly  upset  by  it.  But,  little  by 
little,  the  memory  of  his  danger  gradually  worked  upon  his  emotion. 
He  became  anorexic  and  lost  considerable  flesh.  As  a  matter  of  fact, 
he  experienced  very  belated  emotional  phenomena  which  made  him  pro- 
foundly neurasthenic. 

All  those  authors  who,  in  order  to  establish  a  theory  of  suggestion 
or  simulation  for  hysterical  symptoms,  have  wanted  to  bring  up  as  an 
argument  the  time  that  often  passes  between  the  emotional  shock  and 
the  appearance  of  the  symptoms,  seem  to  us  to  be  wholly  in  the  wrong 
in  not  taking  into  account  the  internal  emotion  which,  in  the  genesis 
of  neuropathic  symptoms,  plays  quite  as  great  a  rôle  as  that  of  external 
emotion,  if  not  a  greater.  We  thus  place  in  emotional  pathogeny  a 
whole  series  of  facts  which  it  seems  to  us  wrong  to  try  to  separate 
from  it. 


THE  RÔLE  OF  EMOTION  AND  EMOTIONALISM.         227 

Is  there  any  relation  between  the  modality  of  physical  disturbances 
brought  about  by  the  emotion  and  the  nature  of  the  emotion  itself? 
As  we  shall  see  further  on,  we  feel  that  this  is  chiefly  a  question  of 
individual  reaction,  varying  more  with  the  individuals  than  with  the 
emotional  causes  themselves.  It  always  seems  to  us,  but  without  being 
able  to  lay  down  this  proposition  as  a  general  thesis,  that  internal 
emotion  gives  rise  chiefly  to  phenomena  which  are  dependent  in  various 
degrees  upon  the  feeling  of  anguish.  The  psychic  manifestations  of 
being  wholly  upset  and  of  intense  excitement  and  inhibition  arise 
chiefly  from  emotional  shock,  and  more  often  follow  it  immediately; 
but  let  us  repeat  that  we  do  not  lay  this  down  as  a  rule.  As  for 
vasomotor  disturbances,  digestive,  cardiac,  or  respiratory  troubles,  they 
seem  to  us  to  belong  indifferently  to  one  emotional  form  or  the  other. 
We  might  say  as  much  of  genito-urinary  disturbances,  and  perhaps 
only  the  phenomenon  of  fainting  and  phobias  of  walking  belong  almost 
exclusively  to  emotional  shock. 

Relations  between  the  Psychical  and  the  Physical  Disturb- 
ances.— Is  there  any  relation  between  the  psychological  and  the  physical 
disturbances  of  emotion  or  any  superposition  whatever? 

It  would  seem  to  us  that  the  reply  ought  to  be  in  the  affirmative,  for 
we  feel  that  there  is  a  very  close  parallelism  between  these  two  kinds  of 
phenomena.  There  are  no  acute  physical  disturbances  without  simul- 
taneous psychic  disturbances.  A  reciprocal  statement  would  not  always  be 
true,  for  in  certain  subjects  emotion  may  produce  only  purely  psychical 
reactions,  without  having  any  physical  disturbances  immediately  asso- 
ciated with  it.  A  psychical  disturbance,  however,  is  constantly  ante- 
cedent to  physical  troubles.  Even  in  the  most  upsetting  emotions  loss 
of  psychological  consciousness  comes  before  the  loss  of  physical  con- 
sciousness. The  fact  that  psychological  consciousness  is  the  first  to  be 
attacked  is  demonstrated  objectively.  We  see  people  who  are  about  to 
faint  making  va^e  movements  which  are  gestures  of  defence  and  which 
show  their  vain  efforts  to  get  hold  of  themselves  or  defend  themselves. 
We  would  readily  say  that  psychical  disturbance  is  the  very  condition 
of  physical  disturbance.  Although  emotion,  particularly  in  its  vasomotor 
reactions,  may  appear  as  a  bulbar  disturbance,  it  is,  however,  only  a 
secondary  phenomenon.  Will  not  a  mental  representation  be  sufficient  to 
produce  vasomotor  disturbances,  such  as  blushing  or  paling?  One  may, 
to  use  a  popular  expression,  ''turn  scarlet"  merely  on  thinking  of  some- 
thing. This  brings  us  to  conceive — a  purely  hypothetical  idea,  but 
more  reasonable  than  probable  and  extremely  important  from  the  point 
of  view  of  the  pathogeny  of  functional  manifestations — ^that  the  fields 
of  intellectual  consciousness  lie  very  close  to  the  fields  of  organic  con- 
sciousness, and  this  explains  why  and  how  an  emotional  preoccupation 
concerning  a  given  organ  affects  the  function  of  that  organ.  This  is 
also  the  explanation  of  the  fact  that  phenomena  of  excitation  or  diffuse 


228     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

psychic  depression  are  able  to  influence  the  general  progress  of  organic 
function,  and  this  naturally  in  a  more  marked  manner  in  those  functions 
which  are  more  particularly  subject  to  nerve  reactions. 

Emotions  Varying  According  to  Individuals. — There  is  no  doubting 
the  fact  that  we  all  react  in  different  ways  to  various  emotional  stimuli. 
Each  one  of  us,  according  to  his  individual  mental  make-up,  responds  or 
fails  to  respond  to  emotional  reactions,  with  more  or  less  ease.  These 
emotional  reactions  themselves,  both  of  a  psychological  as  well  as  of  a 
physical  order,  vary  in  nature  and  intensity  according  to  the  subjects. 
The  degree  of  individual  emotionalism  measures  the  intensity  of  the 
reactions  for  given  emotional  stimuli.  How  and  according  to  what  laws 
quantitatively  and  qualitatively  does  individual  emotionalism  vary? 

First  of  all,  there  is  one  fact  that  is  very  evident, — viz.,  there  is  no 
emotional  stimulus  which  has  an  absolute  intrinsic  value,  «and  v/hich 
is  able  to  arouse  the  same  reaction  in  all  individuals.  All  emotional 
reaction  is  the  function  of  the  particular  personality.  This  may  resolve 
itself  into  tendencies  of  different  kinds.  Some  are  instinctive,  congenital, 
hereditary,  common  to  the  great  majority  of  people  springing  from  the 
same  stock.  Others  are  acquired  and  special,  resulting  from  eccentric 
developments  of  the  personality,  and  are  individual.  Here,  for  ex- 
ample, are  such  instincts  as  the  instinct  of  self-preservation,  the  maternal 
instinct,  even  the  sexual  instinct,  which  enter  as  an  integral  part  into 
the  great  majority  of  the  mental  constitutions  which  v/e  have  been  accus- 
tomed to  consider.  It  is  a  fact  that  anything  that  attacks  these  instincts 
creates  in  a  general  way,  although  with  quantitative  and  qualitative 
variations,  the  same  emotional  reactions. 

Here,  on  the  other  hand,  are  a  miser,  a  man  who  is  jealous,  and 
one  eaten  with  ambitions.  It  is  certain  that  each  will  react  in  a  very 
special  way  to  the  emotional  actions  which  may  affect  that  particular 
domain  in  which  his  personality  is  hypertrophied.  Harpagon  is  in 
despair  over  the  loss  of  his  strong  box,  but  is  quite  indifferent  to  his 
matrimonial  disillusions.  One  man  will  take  the  loss  of  his  money  with 
perfect  sang  froid,  but  will  be  wholly  upset  at  anjrthing  that  touches 
his  affections.  The  other  will  be  unmoved  when  death  has  separated 
him  from  some  member  of  his  family,  but  will  be  beside  himself  at  the 
loss  of  some  position  which  he  had  coveted. 

That  is  to  say,  in  other  words,  the  emotional  reaction  varies  accord- 
ing to  the  personality  of  the  subject  and  with  the  domain  in  which 
the  emotional  excitation  occurs.  But  this  means  also  that  all  develop- 
ment of  the  personality  in  a  certain  sense  inhibits  in  some  way  emotion- 
alism in  other  domains,  on  the  condition  always  that  in  the  zone  thus 
hypertrophied  the  personality  be  entirely  respected  by  the  emotional 
stimulus  which  was  the  cause. 

Therefore,  given  two  opposite  poles  of  mental  constitution,  there 
are  those  individuals  whose  personality  is  more  diffuse,  and  less  special- 


THE  RÔLE  OF  EMOTION  AND  EMOTIONALISM.        229 

ized,  and  those  again  whose  monoideistic  personality  is  more  marked, 
but  who  will  react  less  frequently  to  common  everyday  emotions.  It 
goes  without  saying  that  these  latter  will  on  the  contrary  react  with 
extreme  intensity  if  they  are  touched  in  the  sphere  of  their  particular 
development  ;  thus  it  is  that  the  soldier  who  believes  that  he  is  marching 
to  victory  laughs  at  danger  and  death,  but  in  defeat  loses  his  head, 
and  is  overcome  with  extreme  fear. 

But  there  are  some  monoideisms  which  life  hardly  touches. 

Such  are  the  religious,  and  moral  or  philosophic  monoideisms,  which 
are  so  absorbing  that  individuals  whose  lives  are  filled  with  some  such 
ideas,  or  who,  in  other  words,  have  an  ideal,  are  able  to  fortify  them- 
selves both  against  emotions,  and  against  the  psychoneuroses  which 
proceed  from  them.  The  life  and  death  of  martyrs  of  a  faith,  and  of 
idealistic  philosophers,  furnish  many  striking  examples  of  this.  They 
possessed  a  serenity  of  soul  which  as  applied  to  the  psychoneuroses  is 
one  of  the  best  prophylactics. 

There  are,  on  the  other  hand,  people  whose  mental  make-up  is  such 
that  they  are  able  to  defend  themselves  against  the  invasions  of  emotional 
stimuli,  even  when  they  conflict  with  their  intimate  work.  We  are 
thinking  of  those  individuals  who  are  quite  able  to  feel  emotional  shocks, 
but  who  do  not  prolong  them  by  the  mechanism  of  internal  emotion. 
They  know  how  to  externalize  them,  and  render  them  objective,  and  how 
to  transform  them  rapidly  into  conscious  ideas.  With  them  emotion 
resolves  itself  into  an  intellectual  problem  to  be  solved.  Such  people 
are  rare  it  is  true,  and  instead  of  giving  them  credit  for  the  solid  basis 
of  their  mental  constitution,  we  are  apt  to  reproach  them,  however 
vigorous  their  active  or  passive  intelligence  may  be,  for  not  being  able 
to  feel  things,  because  they  do  not  seem  to  know  how  to  suffer,  as  though 
their  personality  were  colorless  and  something  below  normal.  It  is  none 
the  less  true  that  this  mechanism,  if  it  be  not  exalted  into  a  system  of 
life,  opens  a  path  which  should  not  be  neglected  in  the  treatment  and 
prophylaxis  of  exaggerated  emotionalism. 

As  a  matter  of  fact  the  clinical  study  of  psychoneuroses  brings  us 
face  to  face  with  patients  whose  emotionalism  is  peculiarly  exaggerated 
and  progressively  diffused  in  all  domains.  We  shall  now  take  up  the 
various  factors  which  create  this  exaggeration  and  this  diffusion  of  the 
emotionalism. 

Emotionalism  and  its  Factors. — In  a  great  many  cases  emotionalism 
is  constitutionally  exaggerated.  Even  among  very  young  children  one 
will  find  differences  already  established  in  that  there  are  some  that  be- 
come excited  over  nothing,  who  blush  or  pale,  or  are  disturbed  or  upset 
over  the  slightest  trifles,  and  others  who,  being  more  resistant,  seem  to 
know,  at  the  very  start  of  life,  how  to  live  sanely.  We  shall  see  further 
on  the  part  that  must  be  attributed  to  physical  conditions  under  these 
circumstances,  but  there  is  no  doubt  that  heredity  comes  in,  and  that 
there  are  constitutions  which  are  naturally  emotional,  or  at  least  con- 


230     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

stitutions  which  show  by  physical  phenomena  of  all  kinds  their  emotional 
reactions.  But  it  is  extremely  rare  that  this  excessive  emotionalism 
does  not  bear  a  direct  relation  to  some  peculiar  and  often  very  marked 
trend  of  the  personality. 

These  are  the  children  of  whom  we  say  that  they  have  ''a  sympa- 
thetic nature,"  and  who  even  though  very  young  seem  already  to  'Hake 
things  to  heart." 

This  inner  stratum  in  the  child  is  very  susceptible  to  modification 
by  moral  and  physical  education  ;  unfortunately  modern  education  is  too 
apt  to  encourage  it  when  it  does  not  develop  and  amplify  it. 

From  the  physical  point  of  view  we  accustom  children  to  be  watched 
and  observed.  We  want  to  protect  them  of  course.  They  are  taught  to 
be  afraid  of  things,  and  to  feel  a  certain  sense  of  physical  insecurity; 
in  a  word,  we  are  too  apt  to  bring  them  up  "wrapped  in  cotton."  This 
is  particularly  dangerous.  It  has  often  seemed  to  us  that  it  is  in  just 
such  practices  that  we  could  trace  the  origin  of  emotional  uneasiness 
concerning  the  health  which  later  becomes  a  hypochondriacal  preoccupa- 
tion, and  the  source  of  neurasthenic  conditions  which  are  often  very 
serious. 

From  the  moral  point  of  view  the  same  thing  is  true,  and  if  one 
urges  children  to  be  excessively  sentimental,  and  to  pay  great  attention 
to  moral  scruples  and  questions,  one  runs  a  great  risk  of  preparing  them 
to  be  restless  and  overscrupulous,  and  subject  to  excessive  emotionalism. 
The  adaptation  to  normal  life,  to  its  shocks,  to  the  deceptions  which  it 
brings,  and  the  limitations  and  obstacles  that  go  with  it  can  only  be 
achieved  later,  provided  the  child  has  learned  early  enough  to  be  con- 
scious of  his  personality  and  to  be  sustained  either  by  some  moral  direc- 
tion, external  to  himself,  or  by  sufficient  confidence  in  himself.  It  is 
only  too  true  that  modern  education  fails  to  satisfy  either  one  or  other 
of  these  desiderata. 

Sometimes  education  leads  to  a  very  different  result,  and  it  is  be- 
cause the  child  has  heard  personality  excessively  discussed,  and  because 
he  has  too  much  confidence  in  himself  that  at  the  first  disillusion  the 
whole  structure  will  be  pulled  down.  Thus,  by  different  ways,  one  may 
arrive  at  the  same  result. 

But  education  is  really  prolonged  through  one's  whole  life,  and  the 
individual,  at  a  given  stage  of  his  existence,  is  no  more  than  the  result 
of  the  relationship  between  his  previous  personality  and  the  successive 
events  which  have  modified  it.  But  even  the  individual  who  feels  most 
sure  of  himself  will  not  be  able  to  resist  indefinitely  the  shocks  of  life 
if  they  multiply  and  hurl  themselves  upon  him,  with  too  much  force, 
for  on  the  day  when  he  loses  his  feeling  of  self  security  he  will  become 
truly  emotional.  That  is  to  say  that  he  may  have  emotional  states,  lead- 
ing even  to  a  psychoneurosis,  which,  outside  of  any  previous  mental 
make  up,  may  be  laid  wholly  to  the  storm  and  stress  of  life. 

But  outside  of  these  cases,  unfortunately  too  numerous,  there  are 


THE  RÔLE  OF  EMOTION  AND  EMOTIONALISM.         231 

others  where,  either  on  account  of  their  surroundings,  or  by  the  moral 
trend  of  their  thought,  or  often  also — we  might  almost  say  generally — 
through  unfortunate  medical  advice,  which  has  brought  about  a  sense  of 
secondarily  acquired  physical  or  moral  insecurity,  a  preoccupation  or 
scruple  will  be  born,  and  the  emotional  state  will  follow. 

All  these  later  developments  may  be  summed  up,  by  saying  that' 
emotional  reactions  are  directly  proportioned  to  the  way  in  which  the 
personality  is  affected  and  inversely  proportioned  to  the  degree  in 
which  the  subject  can  keep  his  physical  control.  ^  It  goes  without  saying 
that  the  loss  of  self  confidence  and  the  feeling  of  physical  insecurity 
and  moral  uncertainty  which  lessens  for  the  individual  the  value  of  his 
intellectual  control  bear  in  themselves  a  direct  relation  to  all  the  emotions 
which  have  previously  been  felt. 

Already  we  can  see  the  vicious  circle  into  which  our  patients  may 
be  swept,  who  being  less  intellectually  strong  because  too  emotional  be- 
come more  emotional  in  proportion  to  their  lack  of  intellectual  strength. 
It  is  the  very  same  mechanism  which  presides  over  the  evolution  of  the 
psychoneuroses  in  their  neurasthenic  forms  which  is  almost  sure  to 
become  progressive  unless  some  saving  element  intervenes. 

Physical  Conditions  which  Exaggerate  Emotionalism. — The 
functions  of  physical  life  and  the  functions  of  psychic  life  are  not  in 
human  nature  separated  by  air-tight  compartments,  and,  although  we 
consider,  contrary  to  what  is  usually  admitted,  that  a  great  many 
troubles  in  physical  life  are  brought  about  by  antecedent  disturbances 
of  psychic  life,  we  also  are  not  blind  to  the  fact  that  there  are  a  great 
many  circumstances  where  modifications  of  organic  functions  are  likely 
to  bring  about  psychological  disturbances.  Although  we  refuse  absolutely 
to  admit  that  fatigue,  overwork,  exhaustion,  and  organic  disease  are  the 
immediate  pathogenic  factors  of  the  psychoneuroses,  yet  it  seems  to  us 
very  evident  that  these  elements  may  play  an  important  etiological  rôle 
in  the  development  of  these  affections.  But  it  is  always  through  the 
intermediary  of  psychological  disturbances  that  these  take  effect,  and  on 
ground  that  is  predisposed,  and  in  the  presence  of  superadded  emotional 
causes.  We  do  not  know  any  cases  of  individuals  who  without  some 
emotional  cause  have  been  made  neurasthenic  by  that  kind  of  overwork 
which  might  be -termed  passive.  We  have  never  met,  outside  of  more 
or  less  justified  hypochondriacal  preoccupations  or  of  super-added 
emotional  causes,  with  subjects  who  became  neurasthenic  while  con- 
valescing from  serious  fevers.  These  are  ideas  which  we  have  already 
developed.  But  it  is  none  the  less  true  that  the  various  causes  above 
mentioned,  in  the  presence  of  an  emotional  cause,  are  capable  of  increas- 
ing and  reinforcing  a  neurasthenia. 

In  order  to  understand  this,  it  is  only  necessary  to  notice  what 
happens  in  one's  own  case.  What  person  who  is  tired  and  over-strained 
"wiU  not  be  more  irritable  and  have  less  self-control  and  be  likely  to 


232     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

become  obsessed  on  some  subject?  Especially  one  sees  how  cerebral 
fatigue,  which  by  the  very  nature  of  things  diminishes  the  value  and 
duration  of  intellectual  control,  may  be  capable  of  playing  an  effective 
etiological  rôle  in  the  genesis  of  the  psychoneuroses. 

But  here  again  an  emotional  cause  must  come  in  somewhere,  to  have 
given  the  person  some  reason  for  being  preoccupied  and  obsessed.  As 
we  shall  see  further  on,  simple  fatigue  or  over-tire,  or  so-called  states  of 
exhaustion,  can  never  in  any  degree  be  confused  with  neurasthenic  con- 
ditions, any  more  than  they  can  engender  them.  They  may,  in  the  way 
which  we  have  just  indicated,  contribute  to  the  genesis  of  these  con- 
ditions, which  can  acknowledge  no  single  true  pathogenic  factor  except 
emotion.  Overwork  and  fatigue  are  no  more  a  cause  of  neurasthenia 
than  they  are  of  tuberculosis.  They  create  a  condition  which  predisposes 
to  tuberculosis,  and  which  favors  the  sowing  and  the  proliferation  of 
the  tubercle  bacillus  which  remains  the  only  true  pathogenic  cause.  In 
the  same  way,  by  the  lowered  psychic  and  physical  tone  to  which 
they  subject  the  patient  they  may  become  factors  of  a  greater  emotional- 
ism on  the  one  hand,  as  they  also  constitute  by  themselves  true  causes  of 
emotion  on  the  other  hand.  But  without  emotion  there  are  no  psycho- 
neuroses. 

We  would  like  again  to  draw  attention  in  passing,  but  without 
dwelling  further  upon  it,  to  the  frequent  relations  which  exist  between 
the  increase  of  individual  emotionalism  and  disturbances  of  the  genital 
life.  If  these  latter  act  generally  through  the  intervention  of  disturb- 
ances of  a  psychological  nature,  it  has  seemed  to  us  that  in  certain  cases 
there  may  be  a  direct  connection,  in  some  way  physical,  between  genital 
disturbance  and  emotionalism  of  the  subject.  In  particular,  and  often 
without  there  being  any  question  of  scruples,  regret,  or  remorse,  we 
have  been  convinced  that  the  practice  of  incomplete  coitus,  as  also 
certain  abnormal  sexual  practices,  may  produce  a  direct  effect  upon  the 
emotionalism  of  individuals. 

Individual  Physical  Reactions  of  Emotional  Origin. — The 
physical  modes  of  emotional  reactions  vary  according  to  individuals. 
This  is  a  very  important  fact,  because  it  is  the  key  of  the  mechanism 
by  the  aid  of  which  the  various  functional  manifestations  are  produced. 
Each  person  reacts  to  an  emotion  in  a  way  which  is  peculiarly  his  own. 
Some  have  vasomotor  disturbances,  they  grow  pale,  or  become  flushed, 
another  will  break  into  perspiration  or  have  a  copious  secretion  of  saliva, 
a  third  will  vomit,  while  his  neighbor  will  feel  constriction  of  the  throat 
and  dryness  in  his  mouth.  One  subject  will  find  his  appetite  grow  less 
and  his  digestive  functions  upset,  and  another  under  some  emotional 
influence  will  have  an  attack  of  diarrhœa.  Another  will  have  a  sensation 
of  perineal  tension  with  a  desire  to  urinate  frequently,  either  with  or 
without  excess  of  urine.  This  individual  will  be  taken  with  palpitations, 
and  this  other  will  have  a  tendency  to  faint.    There  are  some  in  whom 


THE  RÔLE  OF  EMOTION  AND  EMOTIONALISM.         233 

the  emotion  is  physically  expressed  by  motor  agitation,  or,  on  the  other 
hand,  by  a  sensation  as  if  the  limbs  were  giving  way,  or  paralyses  of 
the  limbs  or  arms. 

Every  kind  may  be  seen  and  observed.  But  the  most  curious  and 
important  thing  connected  with  such  phenomena  lies  in  this  law,  which 
seems  to  us  to  be  very  general, — namely,  the  persistence  of  the  orienta- 
tion of  the  emotional  reaction. 

We  mean  by  that  that  in  the  given  subject,  whatever  may  be  the 
nature  of  his  emotion,  every  time  that  this  emotion  is  reproduced  it  will 
bring  on  physical  reactions  which  are  always  qualitatively,  if  not  quan- 
titatively, the  same. 

A  subject  in  whom  an  emotion  has  once  been  manifested  by  some 
gastric,  respiratory,  or  cardiac  disturbance,  etc.,  if  he  experience  some 
new  emotion,  or  if  he  is  simply  internally  upset  and  encourages  the 
memory  of  the  emotion  which  he  had,  will  experience  again  or  will  con- 
tinue to  experience  the  same  phenomena  which  he  felt  the  first  time. 
We  have  seen  a  great  many  examples  of  this.  We  have  heard  subjects 
who  were  affected  by  hysterical  paraplegia  tell  us  that,  regularly  and 
constantly  when  any  emotion  comes  over  them,  they  *'feel  it  in  their 
legs."  A  great  number  of  our  false  gastropaths  have  told  us  that  in 
their  cases  indigestion  was  the  only  way,  and  the  same  old  way,  in  which 
they  felt  any  emotional  reaction. 

Are  these  phenomena  of  auto-suggestion?  We  certainly  do  not  be- 
lieve so,  at  least  not  the  first  time  that  these  manifestations  occur. 
Should  we  refer  them  to  individual  predispositions?  The  thing  is  pos- 
sible; but  what  we  want  to  bring  out  is  that  these  physical  reactions 
to  emotion  are  wholly  subconscious  when  they  occur  for  the  first  time. 
It  is  very  important  that  this  fact  should  be  recognized,  for  it  throws 
peculiar  light  on  the  why  and  the  wherefore  as  well  as  on  the  manner 
of  the  localization  of  functional  disturbances. 

The  Emotions.  Hysteria  and  Neurasthenia. — Although  in  the 
genesis  of  hysteria  and  its  accidents,  great  emotion  or  emotional  shock 
seems  to  us  to  play  a  preponderant  rôle,  this  is  very  rarely  true  so  far 
as  the  development  of  neurasthenic  conditions  is  concerned.  Here  it  is 
almost  the  rule  that  emotional  shock,  as  far  as  its  immediate  action  is 
concerned,  has  but  slight  effect  ;  even  when  in  the  preceding  history  of  a 
patient  one  finds  some  considerable  emotional  traumatism,  it  is  not 
always  and  necessarily  to  this  traumatism  in  itself  that  the  development 
of  the  attack  of  neurasthenia  must  be  attributed.  The  individual  who 
in  perfect  health  is  surprised  by  some  emotional  shock  very  rarely  falls 
immediately  into  a  neurasthenic  condition.  This  happens  only  after  a 
long  time,  and  because  he  has  not  been  able  to  free  himself  from  the 
memory  of  the  emotion  which  he  experienced.  The  sudden  mental  dis- 
integration which  the  emotional  shock  creates  may  lead  to  an  hysterical 
symptom,   but,   as   far   as  neurasthenic  conditions  are   concerned,   the 


234     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

mental  and  moral  dislocation  of  a  subject  only  takes  place  progressively, 
as  a  rule.  This  is  because  the  hysteric  has  a  very  peculiar  mentality, 
and  his  moral  condition  is  relatively  little  modified.  The  neurasthenic, 
on  the  other  hand,  whose  mentality  it  is  true  is  affected,  is,  nevertheless, 
«hiefly  affected  in  his  moral  condition.  Now,  if  the  error  in  mental 
representation,  or  the  emotional  discharges  of  any  kind  which  properly 
speaking  constitute  the  symptoms  of  hysteria,  may  be  established,  as 
may  easily  be  conceived,  at'  the  very  start,  the  modifications  of  the 
moral  state,  on  the  other  hand,  necessarily  come  very  gradually.  A  great 
shook  does  not  at  once  produce  that  general  pessimism  which  forms  the 
basis  of  the  neurasthenic's  moral  condition.  To  create  this  condition  it 
is  necessary  for  the  emotional  phenomena  to  be  long  drawn  out,  to  be 
continually  coming  back  again  and  adding  to  and  multiplying  their 
action.  As  a  fact,  when,  roughly  speaking,  the  hysteric  presents  the 
picture  of  one  whose  actions  are  inhibited,  the  neurasthenic  always  ap- 
pears as  one  in  preoccupation, — ^we  might  almost  say,  as  one  having  an 
obsession,' if  this  word  did  not  have  its  own  peculiar  signification  in 
mental  pathology. 

An  example  will  make  our  idea  clearer.  Here,  for  instance,  is  a 
young  woman  who  has  suddenly  heard  of  the  death  of  her  mother.  On 
receiving  the  news,  she  might  have  an  emotional  discharge  in  the  form 
of  an  hysterical  attack.  She  might,  either  with  or  without  progressive 
emotion,  show  the  reaction  either  immediately  or  more  slowly  in  some 
hysterical  symptom,  such  as  a  paralysis  or  contracture  for  example, 
which,  being  fixed  in  her  mind  by  an  error  of  a  mental  representation, 
will,  by  reason  of  her  intense  emotional  condition,  be  kept  up  for  a 
greater  or  less  time.  Under  the  emotional  action  she  has  become  a  pas- 
sive being,  which  registers  and  admits  without  discussion  the  various 
physical  phenomena  which  resulted  from  the  emotional  shock.  We 
have  seen  several  eases  like  this. 

But,  on  the  other  hand,  let  this  same  young  woman  be  with  her 
mother,  who  is  seriously  ill,  and  who  is  fading  away  day  by  day,  let 
her  feel  every  moment  that  the  end  is  approaching,  and  very  different 
phenomena  would  be  produced — if  at  least  her  constitution  was  either 
congenitally  or  in  an  acquired  sense  sufficiently  emotional.  She  would 
at  first  be  uneasy  and  preoccupied,  and,  for  no  other  reason  than  this, 
her  intellectual  control,  her  moral  condition,  and  her  energy  would 
gradually  become  diminished  or  weakened.  Then,  the  emotional  excita- 
tion which  caused  the  continuous  preoccupation  still  pursuing  her,  she 
will  have  need  of  getting  hold  of  herself  and  pulling  herself  up  if  she  is 
to  go  on  living  in  a  way  that  is  at  all  normal.  Later,  when  the  power 
to  act  is  dissolved  by  the  persistent  emotion,  she  would  no  longer  be 
able  to  get  hold  of  herself,  she  would  no  longer  have  the  power  to  pull 
herself  together.  The  emotion  of  preoccupation  would  have  entered  as  a 
constant  inevitable  factor  iiito  all  her  thoughts  and  into  all  her  acts. 
Disoriented  from  a  mental  as  well  as  from  a  moraL  point  of  view,  she 


THE  RÔLE  OF  EMOTION  AND  EMOTIONALISM.         235 

will  have  become  a  neurasthenic,  having  lost  her  intellectual  control,  and 
capable  of  presenting  any  functional  manifestation.  We  must  add,  once 
again,  this  very  important  idea,  that  it  is  the  emotion  itself  which  is 
physically  and  morally  so  fatiguing,  and  that  consequently  the  effective 
phenomena  of  intellectual  and  physical  depression  are  going  to  com- 
plicate the  situation. 

This  is  a  fact  which,  it  seems  to  us,  has  not  been  generally  suiBciently 
considered;  and  yet  just  here  perhaps  is  the  only  real  organic  thing  at 
the  basis  of  neurasthenic  conditions.  Everybody  k^ows  that  any  emotion, 
if  somewhat  deep,  and  chiefly  if  at  all  prolonged,  even  when  it  is  borne 
passively,  will  physically  and  intellectually  wear  out  the  individual  who 
is  suffering  from  it.  Emotion  is  quite  as  fatiguing,  and  in  fact  much 
more  so  than  the  most  violent  exercise,  or  the  most  intense  intellectual 
work.  But  the  effect  which  emotional  preoccupation  brings  about  is  still 
more  marked.  Intellectual  work  which,  in  order  to  be  accomplished 
supposes  a  constant  struggle  against  the  obsessive  preoccupation,  becomes 
peculiarly  painful  and  fatiguing.  No  action  or  decision,  not  even  the 
simplest  affairs  of  life,  may  be  decided  upon  without  the  subject  being 
able  for  the  time  to  disengage  himself  from  the  emotional  cause  which 
unceasingly  invades  his  mind.  Anyone  who,  in  any  degree  whatsoever, 
has  passed  through  a  condition  like  this  cannot  fail  to  appreciate  the 
tremendous  wealth  of  energy  which  certain  people  must  spend  when  they 
are  experiencing  this  weakness  which  constitutes  the  neurasthenic 
condition. 

There  is  no  clearer  pathogeny  of  the  neurasthenic  condition  than 
that  given  spontaneously  by  certain  subjects  who,  being  a  prey  to 
obsessive  preoccupations,  *'feel  at  certain  moments  that  they  are  on  the 
brink  of  neurasthenia."  This  is  because  they  realize  that  the  power  of 
their  energy  is  gone,  not,  as  a  rule,  because  it  was  originally  insufficient, 
— ^though  that  is  a  very  effective  factor  in  many  cases, — but  because  it 
has  been  put  to  too  great  a  strain.  From  the  moment  when  the  will, 
by  which  we  mean  the  physical  and  moral  potentiality  of  an  individual, 
undermined  by  the  effect  of  successive  emotions  and  dislodged  and  disin- 
tegrated by  the  repeated  efforts  made  to  get  hold  of  it, — from  this 
moment  his  will  becomes  utterly  powerless,  the  subject  is  ruled  by  his 
preoccupation,  and  can  no  longer  control  it;  in  other  words,  from  the 
moment  in  which  his  reason  is  carried  away  by  his  emotion  he  is  a 
neurasthenic,  and  contains  within  himself  virtually  all  the  sjmaptoms 
of  this  affection. 

To  give  a  definition  in  a  few  words,  neurasthenia  is  constituted  by  a 
general  ensemble  of  phenomena,  which  result  in  the  non-adaptation  of 
an  individual  to  any  continued  emotional  cause,  and  the  struggle  of 
this  individual  to  bring  about  such  an  adaptation.  One  can  see  how  far 
removed  such  a  conception  is  from  the  organistic  interpretation  of  neuras- 
thenia ;  but  it  would  nevertheless  be  wrong  not  to  take  into  consideration 


236     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

those  very  real  elements  of  fati^e  which  are  directly  produced  by 
emotional  excitation. 

What  are  the  emotional  causes  which  are  found  at  the  base  of  a 
neurasthenic  condition  ?  How  are  they  prolonged,  and  why  ?  What  are 
the  factors  which  reinforce  the  emotional  action?  These  are  the  ques- 
tions which  we  must  now  put  to  ourselves. 

The  Nature  of  Emotional  Causes  which  Engender  the  Psycho- 
neuroses. — ^We  lay  it  down  as  a  general  rule,  which,  according  to  our 
ideas,  permits  of  no  exception,  that  there  is  always  an  emotional  cause 
in  the  genesis  of  neuropathic  states.  If  you  cannot  find  such  a  cause, 
it  is  because  either  your  diagnosis  is  at  fault,  and  that  your  patient  is 
neither  an  hysteric  nor  a  neurasthenic,  or  else  your  patient  is  deceiving 
you.  Let  us  add  that,  unfortunately,  too  often — and  this  explains  the 
lack  of  unity  in  the  medical  comprehension  of  the  psychoneuroses — this 
cause  is  not  even  sought  for  by  the  physician,  who  is  quite  too  ready  to 
apply  himself  to  the  subjective  or  objective  symptoms  presented  by  his 
patients,  and  wholly  to  neglect  the  moral  and  emotional  origin  of  things. 
Then  it  must  be  added,  that — as  the  symptoms  of  the  psychoneurosis 
continue  (as  we  shall  see  further  on)  to  go  on  evolving  on  their  own 
account,  even  when  the  emotional  cause  has  disappeared  from  the  pa- 
tient's field  of  consciousness — it  will  happen  that  even  the  patient,  to 
whom  its  action  appears  to  be  ineffective,  will  neglect  it,  as  not  worth 
relating.  Finally,  although  a  great  many  patients  are  perfectly  willing 
to  unfold  their  whole  past  life  to  the  eyes  of  their  physician,  and 
although  they  will  relate  without  any  discomfort  the  various  unpleasant 
things  that  they  have  had  to  undergo,  there  are  others  who  are  naturally 
very  modest,  and  who,  though  they  might  be  willing  to  narrate  all  the 
details  of  their  physical  life,  yet  refuse  to  disclose  the  miseries  of  their 
moral  life.  This  is  often  also  because  these  things,  necessitating  the 
mentioning  of  a  great  many  people,  are  of  such  an  intimate  nature  that 
the  patient  quite  naturally  hesitates  to  confide  them  to  a  physician, 
v/hose  province  he  does  not  think  it  to  know  all  the  affairs  of  his  moral 
life.  It  is,  therefore,  quite  an  art  for  a  physician  to  know  how  to  draw 
out  from  his  patients  who  are  somewhat  reserved,  and  sometimes  even 
peculiarly  stubborn,  the  real  origin  of  their  sjrmptoms. 

It  is  only  by  an  extremely  careful  questioning,  when  feeling  that 
the  subject  hesitates  to  reply  to  him,  that  he  will  get  an  idea  of  the 
particular  ground  from  which  he  must  keep  back  his  questions  until 
the  patient  has  decided  to  confess  what  always  must  exist, — namely, 
the  moral  cause  of  his  condition.^ 

The  emotional  causes  which  it  is  hardest  to  confess  are  always  those 
which  have  to  do  with  some  hidden  sense  of  guilt  or  with  the  sexual 
life.  We  have  seen  people  become  neurasthenic  because  they  were  con- 
tinually dwelling  in  emotional  preoccupation  concerning  something  which 


THE  RÔLE  OF  EMOTION  AND  EMOTIONALISM.         237 

they  had  done  at  a  former  time  in  their  life.  These  actions  often  dated 
back  for  years,  sometimes  to  childhood  or  to  youth,  and  yet  had  neverthe- 
less pursued  them  during  all  that  time,  finally  upsetting  the  patient's 
morale.  A  certain  man  had  deceived  his  wife  some  ten  years  before,  and 
had  preserved  in  a  peculiarly  obsessive  way  feelings  of  remorse  for  what 
he  had  done.  Another  had  masturbated  when  he  was  about  fifteen  or 
sixteen  years  old,  and  had  retained  the  depressing  ideas  that  he  was  in 
some  way  morally  and  physically  deficient  on  that  account.  This  pa- 
tient became  neurasthenic  because,  having  some  years  before  in  perfect 
good  faith  drawn  several  of  his  friends  into  a  disastrous  business  enter- 
prise, he  had  preserved  the  stinging  memory  of  the  prejudice  that  they 
felt  against  him.  That  patient  in  marrying  had  neglected  to  confess 
to  her  husband  some  hereditary  stigma  existing  in  hçr  family,  and  had 
reproached  herself  violently  for  having  done  so.  This  other  had  married 
her  husband  without  having  confessed  to  him  that  one  of  her  brothers 
had  been  condemned  to  penal  servitude.  We  might  go  on  multiplying 
such  examples,  and  one  can  readily  understand  how  making  such  a  con- 
fession might  be  peculiarly  painful.  How  many  others  have  been  seen 
who  preserved  in  some  way,  either  as  memories  or  as  remorse,  some 
failure  of  their  former  life.  Nothing  more  is  needed  for  a  person  finally 
to  become  wholly  unstrung  morally,  physically,  and  intellectually,  and 
fall  into  neurasthenia. 

Often  the  emotional  cause  must  be  sought  in  the -sexual  sphere.  It 
is  an  attack  upon  one's  modesty,  an  attempted  violation,  a  defloration 
which  was  never  known,  sometimes  unsatisfied  desires  which  the  woman 
experiences  perhaps  as  often  as  the  man,  the  insufficiency  or  the  excesses 
of  sexual  life,  which  come  in,  by  reason  of  the  moral  importance  which 
certain  people  may  attach  to  them,  as  pathogenic  factors  in  the  very 
grave  neurasthenic  conditions  which  follow.  "We  have  seen  women  who, 
being  anxious  to  have  children,  became  neurasthenic  because  the  husband 
insisted  on  coitus  interruptus.  We  have  seen — ^the  fact  is  common 
among  sexual  neurasthenics — ^men  whom  some  accidental  impotence  had 
completely  depressed.  In  this  domain  also  it  is  sometimes  very  difficult 
to  find  the  cause. 

Often  it  is  in  the  realm  of  the  affections  that  the  emotional  cause 
will  be  found.  A  disappointment  in  love,  a  home  which  is  broken  up, 
a  child  who  is  sick  or  one  who  turns  out  badly,  a  family  lacking  in 
affection, — any  one  of  these  may  bring  about  neurasthenic  conditions 
which  will  become  all  the  more  serious  as  the  emotional  cause  persists. 

Less  serious  perhaps,  but  no  less  efficient,  are  the  memories  to  which 
one  cannot  grow  accustomed.  The  loss  of  a  child,  or  a  mother,  or  a 
husband  in  the  realm  of  affections,  the  loss  of  a  situation  or  a  fortune  in 
the  realm  of  material  things,  is  enough  for  the  individual  who  is  haunted 
by  the  memory  of  something  that  is  no  more  and  can  never  be  again,  to 
become  depressed  and  enfeebled. 


238     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

Sometimes  it  is  the  future  which,  comes  into  play,  either  one's  own 
or  that  of  some  one  who  is  very  dear, — these  are  the  situations  in  which 
one  cannot  see  aify  outlook  ahead,  lives  whose  safety  is  threatened  by 
material  or  moral  cares. 

Then  again  there  are  always  the  real  or  supposed  conditions  of  poor 
health,  which  come  in  as  factors  of  emotionalism  and  emotion.  We  have 
seen  people  very  weary  after  some  excessive  work  or  prolonged  strain 
become  neurasthenic,  not  by  reason  of  the  overstrain  itself,  but  by  their 
uneasiness  and  restlessness  at  finding  their  existence  so  reduced  and 
limited. 

We  might  go  on  indefinitely  with  this  nomenclature  of  emotional 
causes.  There  are  all  the  accidents,  even  for  people  who  are  not  inured 
to  them,  all  the  incidents  of  life  which  must  be  reviewed.  We  think 
that  we  have  said  enough  to  show  how  the  apparent  lack  of  constancy  of 
emotional  causes  makes  them  difficult  to  determine.  But  we  cannot 
repeat  too  often  that  an  emotional  cause,  whether  visible  or  hidden, 
always  exists,  and  that  the  most  important  thing  is  to  know  how  to 
find  it. 

\Is  it  possible  to  establish  any  order  of  comparative  frequency  in  these 
emotional  causes?  This  appears  to  us  a  difficult  thing,  and  the  patho- 
genic importance  of  these  causes  varies  essentially  according  to  surround- 
ings. Preoccupations  of  a  social  and  material  order  are  met  evidently 
much  more  frequently  in  the  poorer  classes  of  society.  Emotional  causes 
due  to  obscure  and  subtle  scruples  belong  much  more  naturally  to  the 
educated  world.  One  can,  therefore,  see  how  statistics  based  upon  these 
causes  would  vary  according  to  the  social  status  considered,  according 
to  race,  according  to  countries,  and  the  peculiar  trend  of  the  men- 
talities. Nevertheless,  we  have  endeavored  to  establish  some  such  sta- 
tistics, and  we  give  them  for  what  they  are  worth.  Not  counting  the 
great  emotional  traumatisms,  our  statistics  give  us  the  following  table 
in  the  series  of  emotional  causes: 

PsycHoneuroses  where  the  emotional  cause  is  due  to — 

1.  Preoccupations   of   a  physical   nature 27  per  cent. 

2.  Affective  preoccupations   24  per  cent. 

3.  Sexual    preoccupations    22  per  cent. 

4.  Scruples  of  all  kinds  14  per  cent. 

5.  Material  preoccupations   13  per  cent. 

The  only  really  interesting  fact  which  seems  to  us  to  be  contained 
in  this  list  is  the  importance  of  the  sexual  factor  in  the  genesis  of  the 
psychoneuroses.  It  is,  on  the  other  hand,  quite  as  unexpected  to  see 
scruples  of  all  kinds  taking  the  precedence  as  emotional  causes  over 
preoccupations  concerning  material  things.  If  we  can  believe  our  per- 
sonal experience,  a  man  thinks  a  great  deal  about  his  health,  and  a 
great  deal  about  his  affections,  and  a  good  deal  about  his  sexual  life. 
The  material  questions  of  life  occupy  him  less.     Fï-om  the  way  we 


THE  RÔLE  OF  EMOTION  AND  EMOTIONALISM.        23^ 

generally  look  upon  life  this  idea  is  rather  unexpected,  and  one  which 
tends  to  raise  the  neurasthenic  in  our  esteem,  because  it  is  a  part  of  his 
personality  to  put  his  affections  before  his  interests. 

The  Factors  of  the  Persistence  op  the  Emotional  Idea  in  Con- 
sciousness.— The  expressions  "Forget  it,"  ''Leave  it  alone,"  ''Give  it 
up,"  "Renounce  it,"  "Make  up  one's  mind  to  resign  one's  self,"  etc., 
express  the  manner  in  which  normal  subjects  behave  in  the  presence 
of  the  different  things  that  happen  to  them  in  life. 

In  normal  individuals,  even  the  action  of  persistent  preoccupation 
does  not  necessarily  inhibit  their  activity.  A  subject  whose  mentality  is 
well  balanced  tries  and  succeeds  in  distracting  himself,  we  have  already 
seen,  according  to  the  very  quality  of  the  emotion,  and  according  to  the 
personality  of  the  individual  having  it,  that  it  w^as  more  or  less  easy 
to  prevent  the  total  invasion  of  the  emotions.  But,  whatever  might  be 
the  particular  direction  taken  by  the  mentality,  and  whatever  may  be 
the  nature  of  the  emotional  causes  which  come  into  play,  the  neuras- 
thenic presents,  as  we  have  already  pointed  out,  a  mental  constitution 
which  makes  him  particularly  susceptible  to  emotional  actions,  in  the 
presence  of  which  he  sometimes  finds  himself  completely  helpless.  To  a 
large  extent  constitutionally,  and  partly  by  reason  of  education,  by  the 
moral  hygiene  of  life,  and  by  the  various  experiences  which  may  be 
scattered  through  it,  the  mentality  of  a  subject  which  is  capable  of 
becoming  neurasthenic  may  be  summed  up  in  two  words,  emotional  and 
obsessionable.  To  w^hat  degree  may  these  two  words  be  considered  as 
one?  At  first  sight  it  seems  as  though  they  applied  to  very  different 
phenomena.  The  hysteric  who  is  very  emotional  is  not,  as  a  rule, 
obsessionable. 

Nevertheless,  one  may  easily  see  that  the  tendency  to  obsessions 
would  be  naturally  inversed  in  a  subject  with  a  faculty  of  adaptation. 
It  is  true  that  ideas  which  do  not  become  a  part  of  the  personality  have 
a  chance  to  persist  in  the  field  of  consciousness.  If,  to  return  to  the 
ideas  of  Janet,  one  looks  upon  emotion  as  a  reaction  of  inadaptation, 
then  the  power  to  be  obsessed  in  some  way  resolves  itself  into  emotional- 
ism. It  is  only  one  of  the  reactions — psychic  this  time — of  emotion. 
And  we  would  freely  say  that  the  characteristic  of  a  candidate  for 
neurasthenia  is  to  respond  to  emotional  actions  under  the  particular  form 
of  obsessions. 

Without  dwelling  on  this  rather  delicate  psychological  problem,  we 
would  like  to  show  what  are  the  extrinsic  circumstances  of  the 
emotional  idea  which  favor  its  persistence  in  the  field  of  individual 
consciousness.  In  other  words,  apart  from  the  mental  constitution  itself 
of  the  neurasthenic  which  more  readily  than  another  makes  it  fasten 
upon  a  preoccupation  and  exaggerate  it,  apart  from  the  psychological 
deficiency  which  emotional  states  cause  in  the  long  run,  apart  from  the 


240     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

value — either  intrinsic  or  relative  in  the  personality  of  the  subject 
attacked — of  the  emotion  in  question,  what  are  the  common  mechanisms 
which  in  all  individuals,  neurasthenic  or  not,  encourage  an  idea  and 
maintain  a  preoccupation  ? 

First  of  all>  the  question  of  time  comes  in.  It  is  very  evident  that 
the  longer  an  idea  has  occupied  the  field  of  consciousness  the  more 
difficult  it  will  be  to  uproot  it,  and  the  harder  it  wall  be  to  forget  it.  This 
is  because  the  preoccupation,  being  associated  with  all  the  mental 
acquisitions  of  daily  life,  will  have  all  the  more  chance  of  being  called 
up  as  these  associations  become  more  multiplied.  It  is  thus  that  the 
surroundings,  the  list  of  details  in  which  the  preoccupation  will  have 
become  developed,  will  constantly  recall  it,  because  all  the  pictures 
which  its  environment  or  this  list  may  furnish  have  already  been  previ- 
ously associated  with  the  idea  which  has  become  obsessive.  Now,  this 
power  of  calling  up  people  and  things  is  by  no  means  negligible,  be- 
cause a  whole  series  of  therapeutic  regulations  depend  upon  it,  as  we 
shall  see  later. 

But  as  far  as  certain  preoccupations  are  concerned,  such  as  hypo- 
chondriacal preoccupations,  it  happens  that  among  certain  subjects  the 
calling  forth  of  these  is  in  some  way  voluntary,  and  in  direct  relation  to 
a  badly  organized  moral  hygiene.  All  individuals  who,  either  by  habit 
or  education,  are  accustomed  to  observe  and  scrutinize  themselves,  both 
physically  and  morally,  will  encourage  by  those  very  means  every  pre- 
occupation of  a  physical  nature  and  every  moral  scruple  which  other- 
wise would  have  been  nothing  but  a  mere  passing  incident  in  their  lives. 

It  happens  again  that  such  evocation  may  be  provoked  exteriorly  to 
the  subject  himself.  Here  is  an  individual,  a  false  gastropath  or  a  false 
enteropath,  whose  physician  has  advised  him  to  analyze  his  sensations 
and  to  examine  carefully  his  excrement.  With  such  proceedings  how 
can  it  be  otherwise  than  for  the  hypochondriac  to  become  daily  more 
fixed  in  his  way  of  thinking?  Here,  on  the  other  hand,  is  a  man  suffer- 
ing from  scruples,  who  is  encouraged,  by  inadequate  or  badly  under- 
stood moral  advice,  repeatedly  to  examine  his  conscience.  His  uneasi- 
ness concerning  these  scruples  will  of  necessity  increase.  Furthermore, 
we  will  frankly  say  that,  in  certain  subjects  with  rather  weak  mentality, 
such  medical  or  moral  treatments  are  capable  of  creating  by  themselves 
an  emotional  preoccupation  which  is  a  factor  of  secondary  neurasthenic 
conditions.  All  these  ideas,  over  which  we  are  now  passing  rapidly,  we 
shall  take  up  later  when  we  describe  the  prophylactic  treatment  of  the 
psychoneuroses.  They  are  of  considerable  importance  for  the  physician 
as  well  as  for  the  spiritual  adviser,  who  would  do  well  to  take  for  their 
guidance  the  adage  Primum  non  nocere. 


CHAPTER  XV. 

WHAT  DOES  NOT  BELONG  TO  NEURASTHENIA.      WHAT  DOES  NOT  BELONG 

TO  HYSTERL\. 

We  SHALL  study,  a  little  further  on,  the  essential  mechanism  of 
various  hysterical  symptoms  and  various  neurasthenic  manifestations. 
But,  before  beginning  this  study,  it  seems  to  us  that  it  would  be  wise 
to  define  exactly  the  breadth  and  comprehension  that  we  give  to  the 
two  terms  hysteria  and  neurasthenia.  It  seems  to  us  that  a  certain 
number  of  morbid  conditions,  whose  relations  to  neurasthenia  and 
hysteria  are  more  apparent  than  real,  have  been  wrongly  and  too  often 
included  with  the  psychoneuroses.  In  the  description  of  these  affections 
it  has  been  perhaps  too  frequently  forgotten  that  only  those  pathological 
phenomena  should  be  classed  as  one  which  have  a  common  pathogenic 
causation. 

Now,  there  is  no  doubt  that  in  the  popular  conception  of  hysteria, 
as  in  that  of  neurasthenia,  one  groups  together  all  kinds  of  troubles  with 
widely  different  origins,  and  which  have  no  relation  whatever  to  the 
psychoneuroses  except  through  more  or  less  occasional  bonds  of 
association. 

First  of  all,  so  far  as  neurasthenia  is  concerned,  there  are  all  those 
phenomena  of  simple  fatigue  which  we  consider  to  have  no  pathogenic 
affinity  to  the  neurasthenic  condition.  The  individual  who,  physically 
or  iatellectually,  overstrains  himself  in  his  work,  especially  if  his  feel- 
ing of  overstrain  is  sudden  and  if  he  is  not  sufficiently  in  good  training 
to  stand  it,  will  get  to  the  point  after  a  greater  or  less  length  of  time 
where  he  is  really  exhausted,  or  *^ knocked  out."  Physical  effort  will 
become  absolutely  impossible  or  painful  to  him;  intellectual  effort  will 
be  distressing  and  often  not  adequate  to  the  amount  of  work  put  forth. 
Between  these  extreme  conditions,  and  the  simple  sensation  of  the  sub- 
ject who  sees  his  vacation  approaching  with  pleasure  because  he  finds 
himself  a  little  tired,  there  is  every  shade  of  gradation.  But,  just  as  we 
would  never  dream  of  calling  a  man  a  neurasthenic  because  he  had 
worked  hard  and  feels  the  need  of  rest,  so  it  seems  to  us  illegitimate  to 
describe  as  neurasthenic  a  man  who  having  worked  too  hard  shows 
for  the  moment  all  the  signs  of  intense  physical  and  cerebral  fatigue 
which  have  obliged  him  to  stop  work.  Every  transition  may  be  found 
between  slight  fatigue  and  exhaustion.  There  is  no  reason  why,  basiug  it 
on  a  simple  question  of  degree,  one  should  put  the  patient  in  one 
nosological  class  or  another. 

The  soldier  who  after  prolonged  marches  or  the  sportsman  who  after 
repeated  climbs  had  fallen  exhausted  are  no  more  neurasthenics  than  the 
16  241 


242     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

person  who  has  read  too  much  by  artificial  light  or  has  used  his  voice  to 
excess  and  who  is  obliged  to  rest  his  eyes  or  his  vocal  cords. 

It  may  happen  that,  having  abruptly  passed  the  capacity  for  which 
he  was  trained,  the  subject  may  suddenly  find  himself  incapable  of 
continuing  his  efforts,  because  there  have  come  in  all  those  phenomena 
of  intoxication  due  to  excessive  fatigue.  It  may  happen  that  then  he 
will  be  obliged  to  rest  for  a  much  longer  time  than  he  supposed  would 
be  necessitated  by  the  work  which  he  had  accomplished.  But,  neverthe- 
less, he  is  not  a  neurasthenic  for  that  reason.  He  may  become  one 
if  in  addition  to  his  feelings  of  fatigue  there  should  be  added  any  con- 
tinued emotional  state  on  which  might  be  grafted  obsessive  preoccupa- 
tions. That  fatigue  may  play  its  part,  in  a  certain  measure,  by  reinforc- 
ing emotionalism,  is  understood,  but,  although  it  may  in  this  way  con- 
stitute an  etiological  factor  of  neurasthenia  as  of  many  other  affections, 
it  is  not  a  direct  pathogenic  factor  of  it,  it  does  not  of  itself  constitute 
a  neurasthenic  phenomenon. 

Does  this  mean  to  say  that  the  phenomena  which  one  observes  either 
objectively  or  subjectively  among  those  who  are  exhausted  differ  essen- 
tially from  the  so-called  symptoms  of  exhaustion  which  may  be  found 
physically  or  psychically  among  neurasthenics?  By  no  means.  But 
the  organism  only  responds  to  these  different  causes  by  a  certain  number 
of  simple  reactions.  Whether  the  impression  of  fatigue  comes  from  real 
and  true  overwork,  whether  it  is  in  relation  to  some  continued  emotional 
cause,  or  whether  it  constitutes  merely  a  purely  subjective  phenomenon, 
patients  all  express  their  impressions  about  it  in  the  same  words.  In 
the  same  way,  to  make  a  comparison,  a  feeling  of  heat,  whether  it  be  due 
to  outside  temperature  or  to  a  fever,  or  is  in  relation  to  a  simple  auto- 
suggestion, will  be  expressed  in  the  same  manner  by  the  same  or  by 
different  subjects. 

We  have  already  insisted  several  times  on  this  fact,  that  overwork, 
whether  followed  or  not  by  fatigue  or  exhaustion,  does  not  enter  as  a 
pathogenic  factor  of  neurasthenia.  But  we  have  also  said  that  in  a 
great  number  of  cases  the  overwork  is  accompanied,  as  a  matter  of  fact, 
by  associated  emotional  conditions.  This  we  think  accounts  for  the 
explanation  of  the  too  great  importance  which  one  has  attached  to  fatigue 
and  to  exhaustion  in  the  genesis  of  neurasthenia.  It  is  the  associated 
emotional  condition  and  not  the  overstrain  in  itself  which  is  the  cause, 
and  the  importance  of  the  emotional  cause  is  all  the  greater  when,  either 
intrinsically  or  on  account  of  fatigue,  the  subject's  emotionalism  is  more 
affected. 

Fatigue,  exhaustion,  neurasthenia  are  therefore  words  which  may  be 
found  associated  in  the  patient's  history.  But,  as  there  are  a  great 
many  neurasthenics  who  originally  did  not  suffer  at  all  from  fatigue, 
and  as  there  is  an  equally  great  number  of  overworked  people  who  will 
never  become  neurasthenics,  it  seems  to  us  perfectly  legitimate  as  well 


NEURASTHENIA  AND  HYSTERIA.  243 

as  neeessarj^  to  wipe  the  simple  phenomena  of  fatigue  and  exhaustion 
out  of  the  neurasthenic  picture. 

In  the  discussion  on  the  rôle  of  emotion  in  the  genesis  of  neurasthenia,^ 
we  note  the  following  lines  by  Babinski:  "The  typical  form  of  the 
disease  [neurasthenia]  is  represented  by  what  is  called  constitutional 
neurasthenia,  which  appears  in  youth  in  subjects  who  until  that  time 
were  able  to  work  intellectually  and  physically  in  a  normal  way.  The 
least  effort  tires  them  ;  they  are  exhausted  after  reading  a  few  pages  or 
writing  a  letter.  This  form  of  affection  may  be  developed  without 
there  having  been  any  preliminary  overwork,  and  in  individuals  who 
are  not  especially  susceptible  to  emotion." 

The  type  of  patient  to  whom  Babinski  alludes  is  well  known,  but 
it  includes  a  great  many  different  cases  of  which  only  a  few  are  in- 
cluded in  the  true  neurasthenic  picture.  There  are  people  who,  being 
constitutionally  very  emotional,  are  excessively  and  emotionally  pre- 
occupied over  an  examination  or  competition  which  they  are  going  to 
pass.  Such  people  may  become  true  neurasthenics.  There  are  others 
who  excuse  an  inferiority  which  they  have  really  foreseen  by  a  purely 
subjective  helplessness  which  is  sometimes  frankly  put  on.  This  is  a 
neurasthenia  which  is  fostered  by  teachers  and  parents  and  it  is  not  so 
infrequently  seen. 

But  the  interesting  point  in  diagnosis  has  to  do  with  certain  sub- 
jects who  really,  without  autosuggestion  or  without  simulation,  without 
any  marked  overwork  or  without  emotion,  fall  into  a  state  of  fatigue  or 
exhaustion  which  nothing  seems  able  to  explain. 

It  seems  to  us  that  it  would  be  rather  a  hasty  solution  to  say,  as 
Babinski  does,  that  these  young  people,  who  often  later  in  life  bear 
themselves  in  an  extremely  energetic  manner,  are  attacked  with  nervous 
exhaustion,  and  that  it  is  a  question  of  so-called  constitutional  neuras- 
thenia. It  seems  to  us  that  here  it  is  a  question  purely  of  organic  de- 
ficiency. These  troubles  come  on  at  the  age  when  young  girls  become 
neurotic,  and  often  occur  in  those  who  are  suffering  from  amenorrhœa. 
This  is  the  age  also  when  tuberculosis  so  frequently  becomes  established, 
or  w^hen  mitral  stenosis  may  become  a  true  disease  of  the  heart.  It  is 
the  age  in  fact  when  all  kinds  of  troubles  occur  which  have  nothing  to 
do  with  neurasthenia,  and  which  are  troubles  connected  with  growth  and 
evolution.  On  account  of  constitutional  debility  or  by  some  anomaly  of 
development,  the  subject  may  not  be  able  to  stand  the  strain  of  organic 
growth  which  has  taken  place  at  that  time,  and  which  is  expressed  in 
other  parts  of  the  body  by  disturbances  connected  with  the  blood-vessel 
glands  which  may  be  detected  by  close  observation.  If,  as  a  matter  of 
fact,  one  examines  such  patients  very  carefully,  one  will  find  anomalies 
in  the  development  of  the  pilary  system,   as  well  as  heart  troubles, 

*  Revue  Neurologique,  December  30,  1909,  p.  1633. 


244     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

usually  in  the  form  of  tachycardia,  and  also  vasomotor  phenomena  such 
as  congestions,  blushing,  hot  flushes,  etc. 

These  are  what  we  might  call  rather  indefinite  organic  conditions. 
It  would  be  wrong  to  consider  them  as  an  integral  part  of  neurasthenic 
conditions,  just  as  it  would  also  be  incorrect  to  make  use  of  their  presence 
to  establish  a  theory  of  the  psychoneuroses,  based  on  a  blood-gland 
pathogeny. 

We  would  say  the  same  thing  concerning  what  has  been  called 
neurasthenia  of  the  menopause  and  neurasthenia  of  the  critical  age  of 
men.  There  is  no  doubt  that  this  period,  which  separates  maturity 
from  what  might  properly  be  called  old  age,  is  really  a  period  of  some 
organic  danger.  Statistics  prove  it  in  showing  an  increase  of  mortality 
toward  the  fiftieth  year,  after  which  period  it  seems  as  though  human 
beings  took  a  new  lease  of  life.  At  this  time  in  life  the  oscillations  of 
the  organism  which  is  seeking  its  equilibrium  may  be  translated  into 
feelings  of  depression,  exhaustion,  and  fatigue;  of  that  there  is  no 
question.  Just  now  we  have  been  considering  organic  disturbances  of 
evolution;  here  disturbances  of  involution  are  the  cause.  It  is  quite 
possible  that  pure  neurasthenic  conditions  by  means  of  hypochondriacal 
preoccupations  may  become  established  at  this  period  of  life  by  reason 
of  an  exaggerated  state  of  emotionalism.  But  we  do  not  believe  that  we 
should  consider  these  conditions  of  fatigue  which  disappear  spontane- 
ously when  organic  equilibrium  has  been  reestablished  as  an  integral 
element  of  neurasthenia.  This  would  seem  to  us  no  more  logical  than  to 
regard  as  a  neurasthenic  a  man  in  the  early  stages  of  general  paralysis  or 
arteriosclerosis. 

Nevertheless,  in  these  patients  one  may  see  the  same  physical  ex- 
haustion and  psychic  debility.  One  does  not  consider  them  as  neuras- 
thenics because  there  are  superimposed  upon  their  subjective  symp- 
tomatology such  objective  signs  as  pupillary  or  reflex  reactions  in 
some  cases,  and  arterial,  cardiac,  and  urinary  in  others.  One  speaks 
of  the  false  neurasthenia  of  general  paretic  or  arteriosclerotics.  It 
seems  to  us  quite  as  legitimate  to  consider  as  autonomous,  and  without 
any  relation  to  true  neurasthenia,  the  false  neurasthenias  of  either  the 
masculine  or  feminine  menopause.  Their  organic  substratum  is  poorly 
defined.  The  blood-glands  may  also  be  involved;  in  fact  all  the  con- 
ditions very  closely  resemble  the  analogous  symptoms  which  one  may 
observe  in  Addison's  disease  or  exophthalmic  goitre. 

However,  the  development  of  these  pseudo-neurasthenias  of  evolu- 
tion or  involution  plainly  reveals  their  nature.  Sometimes  they  yield 
spontaneously  and  disappear  completely  after  a  greater  or  less  length 
of  time.  Sometimes  they  disappear,  it  is  true,  only  to  make  way  for 
a  distinctly  defined  depressive  psychosis  or  an  organic  disease.  But  in 
a  general  way,  during  the  whole  course  of  their  evolution,  they  show  a 


NEURASTHENIA  AND  HYSTERIA.  245 

symptomatic  constancy  which  is  never  found  in  true  neurasthenia, 
the  variability  of  whose  symptoms  is  one  of  its  chief  characteristics. 

Many  other  patients  are  also  considered  as  neurasthenic  under  the 
idea  that  they  are  suffering  from  exhaustion,  who  are  in  reality  suffering 
from  some  purely  organic  trouble,  which  too  often  does  not  appear  until 
much  later.  We  would  be  obliged,  if  we  were  logical  and  wished  to 
confine  ourselves  to  the  classical  conception  of  neurasthenic  conditions, 
to  describe  biliary  neurasthenias,  renal,  suprarenal,  and  thyroid  neuras- 
thenias, etc.  Descriptions  of  this  kind  have,  as  a  matter  of  fact,  been 
made.  The  man  who  is  intoxicated  by  opium,  or  chloral,  or  cocaine 
might  in  this  way  be  considered  a  neurasthenic  when  he  is  deprived  of 
his  poison,  and  the  man  who  is  suffering  from  lead  poisoning  and  who 
is  threatened  with  encephalopathy  ought  also  to  be  put  in  the  same 
nosological  class. 

These  developments  enable  us  to  see  that  a  state  of  exhaustion  lead- 
ing, as  a  rule,  to  extremely  different  phenomena  can  give  but  a  very 
inadequate  definition  of  the  neurasthenic  condition.  Can  one  find  its 
specific  qualities  in  the  mental  condition  of  the  patient?  Must  one 
necessarily  be  a  neurasthenic  because  he  is  depressed,  or  obsessed,  or 
has  phobias  ?  By  no  means,  and  yet  just  here  there  are  errors  made  in 
diagnosis  every  day,  due  to  the  stupid  confusion  shown  by  even  the 
most  intelligent  physicians. 

In  the  same  way  very  often  a  mild  depressed  mania  is  confounded 
with  neurasthenia.  We  do  not  refer  now  to  the  custom  by  which,  for 
politeness'  sake,  characteristic  psychoses  are  described  either  as  a  serious 
or  an  acute  neurasthenia.  In  the  diplomatic  language  of  the  press,  for 
example,  not  a  day  goes  by  but  that  one  may  read  that  some  one  has 
committed  suicide  in  an  attack  of  acute  neurasthenia.  It  is  evident  that 
families  would  much  prefer  to  include  a  neurasthenic  among  their 
members  rather  than  a  man  who  had  a  psychosis.  But  such  an  abuse 
of  the  term  is  really  dangerous.  We  have  seen  a  great  many  neuras- 
thenics who  have  been  oppressed  by  these  facts  in  a  peculiarly  un- 
favorable manner.  They  have  been  thrown  into  an  intensely  emotional 
condition,  and  the  phobia  of  suicide  has  followed. 

What  we  have  in  mind  is  a  slightly  depressed  condition  without  any 
great  feeling  of  anxiety,  without  absolute  insomnia,  and  without  very 
extremely  marked  psychic  or  moral  depression.  To  tell  the  truth,  the 
diagnosis  is  sometimes  difficult,  and  can  be  made  chiefly  only  through 
the  development  of  the  symptoms  and  by  the  history  of  the  patient- 
The  existence  of  former  attacks  under  a  manic  or  depressed  form  will 
often  enable  one  to  detect  the  true  nature  of  the  trouble;  but  the  real 
element  on  which  the  diagnosis,  whatever  it  may  be,  depends  lies  chiefly 
in  the  constancy  and  continuity  of  the  psychic  symptoms  presented  by 
these  patients.  In  their  cases  psychotherapy  is  purely  illusory,  for  they 
are  convinced  of  the  incurability  of  their  condition.     And  when  one 


246     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

finds  one's  self  in  the  presence  of  a  patient  whom  it  is  absolutely  im- 
possible to  infuse  with  any  hope,  who  presents  a  mental  or  mor'al 
systematization  through  which  one  cannot  penetrate,  it  is  more  than 
probable  that  this  patient  is  not  a  neurasthenic,  but  that  he  is  involved 
in  a  manic-depressive  psychosis.^  Often  also  the  suddenness  of  the 
onset  is  characteristic  of  a  melancholic  condition. 

A  cyclothymic  constitution  offers  material  for  a  great  many  errors 
in  diagnosis.  But  here  one  finds  one's  self  confronted  by  associated 
conditions.  There  are  subjects  who,  on  seeing  their  mentality  and 
moral  nature  suddenly  changed,  and  feeling  themselves  constantly 
hindered  and  stopped  in  an  activity  which  is  inclined  to  be  brimming 
over  with  energy  in  the  in-between  periods,  become  disturbed,  pre- 
occupied, and  depressed.  Here  it  is  a  case  of  the  superposition  of  a 
continuous  emotional  psychoneurosis  such  as  neurasthenia  upon  an 
organic  psychopathic  condition.  To  distinguish  what  belongs  to  one  and 
what  to  the  other  of  the  two  elements  of  this  pathological  complex  can 
be  accomplished  only  by  referring  to  the  patient's  previous  history. 

There  is  apt  to  be  eonfusion  also  in  two  senses  between  neurasthenic 
states  and  hypochondriacal  conditions,  whether  one  calls  a  true  hypo- 
chondriac a  neurasthenic  or  whether,  on  the  contrary,  one  considers  as 
a  neurasthenic  a  mentality  which  is  hypochondriacal.  Although  one 
would  not  be  apt  to  make  a  mistake  in  a  certain  number  of  cases  when 
the  hypochondriacal  obsession  is  very  characteristic  and  gets  to  the 
point  of  frenzied  ideas,  there  are,  on  the  other  hand,  very  often  pa- 
tients whose  hypochondria  is  more  diffuse  and  more  difficult  to  define. 
Not  but  what  there  are  numerous  elements  by  which  a  diagnosis  may 
be  established.  If  one  questions  a  minor  type  of  hypochondriac  who 
complains  about  his  head,  and  if  you  assure  him  that  his  nervous  system 
is  all  right,  he  will  begin  by  doubting  your  veracity,  and  will  put  a 
series  of  questions  to  you,  of  which  the  majority  will  begin  with  these 
words  :  ^  '  But  how  does  it  happen  then  ?  '  '  Such  a  one  has  nothing  charac- 
teristic and  may  be  found  among  the  neurasthenics.  Bi|t  what  is  quite 
specific  is  to  see  a  patient,  without  having  passed  through  any  emotional 
phase,  abruptly  abandon  his  cerebral  systematization  and  say,  **If  it 
is  not  my  head,  then  it  is  my  heart,  my  lungs,  my  stomach,  or  my 
intestines  which  are  diseased."  He  will  thus  run  through  the  whole 
field  of  pathological  possibilities,  and,  if  you  have  had  the  patience 
to  pursue  him  from  one  position  to  another,  you  will  abandon  the  siege 
when,  having  completed  his  cycle,  he  returns  to  the  starting-point  and 
begins  to  tell  you  all  over  again  about  his  head. 

With  the  neurasthenic  there  is  nothing  of  this  sort.  He  may  have 
one  or  several  preoccupations,  not  hypochondriacal  but  organic,  but 
these  preoccupations  have  a  true  reason  for  existing.     The  false  gas- 

*  Cyclothymia  is  a  frequently  used  word  for  this  state.  See  Jelliffe,  Am.  J. 
Insanity,  1911  [Tr.]. 


NEURASTHENIA  AND  HYSTERIA.  247 

Jropath  has  painful  digestion,  the  false  cardiac  has  tachycardia,  the 
false""ptrtmonary  has  dyspnœa,  the  false  urinary  has  abnormal  urethral 
or  vesical  sensations.  The  troubles  felt  by  these  patients  are  functional 
in  their  nature, — ^that  is  understood.  They  are  of  emotional — that  is, 
of  a  subjective  and  psychic — origin  :  so  much  so  that  their  systematiza- 
tion  is  sure  to  be  sufficiently  distinct,  so  that  a  false  gastropath  when 
once  cured  does  not  become  a  false  cerebral,  a  false  urinary,  etc. 

However,  the  most  important  element  of  diagnosis  does  not,  to  our 
way  of  thinking,  lie  in  this.  That  element  hes  chiefly  in  the  origin  of 
the  symptoms.  It  is  true  that,  under  the  influence  of  emotions  and  the 
various  experiences  of  life,  hypochondriacal  conditions  may  be  ex- 
aggerated, but  they  are  exaggerated  as  a  whole.  As  for  the  hypo- 
chondriac preoccupation  itself,  it  constitutes  originally  a  purely  in- 
tellectual conception,  apropos  of  which,  but  secondarily,  the  patient  may 
really  work  up  an  emotion,  but  which  is  not  of  emotional  origin.  With 
the  neurasthenic  things  take  place  in  the  opposite  way.  The  localiza- 
tion is  always  due  to  an  emotional  cause,  and,  if  intellectual  interpretar 
tions  follow,  it  is  they  and  not  the  emotional  phenomena  which  are 
secondary. 

In  the  same  way,  when  we  are  told  that  our  patients  who  are  attacked 
with  false  pathies  are  hypochondriacs  and  not  neurasthenics,  we  cannot 
but  think  that  the  patients  have  not  been  thoroughly  examined,  and 
that  such  statements  can  only  be  attributed  to  a  very  inexact  conception 
of  things. 

There  now  remains  a  last  category  of  patients  to  be  described,  which 
are  classified  by  Janet  in  the  same  nosological  list,  the  psychasthenics. 
In  what  measure  psychasthenia  may  be  confused  with  manic-depressive 
psychosis  and  Magnan's  syndromes  of  mental  degeneracy  is  a  problem 
which  remains  to  be  solved.  But  under  whatsoever  title  these  patients 
may  be  considered  as  resembling  neurasthenics,  it  is  something  which 
we  cannot  admit  as  a  fact.  We  feel  that  to  regard  psychasthenia  **as 
a  psychic  form  of  neurasthenia"  (Dupré)  is  to  want  to  force  phenomena 
into  this  psychoneurosis,  which,  in  whatever  way  they  may  be  interpreted, 
have  nothing  to  do  with  it. 

It  is  perfectly  evident  to  us  that  a  perversion  or  an  obsession  may 
serve  as  a  continued  emotional  cause,  and  preside  in  this  way  at  the 
establishing  of  superadded  neurasthenic  states.  Nor  does  it  seem  at  all 
doubtful  that  there  are  psychasthenics  whose  life  has  been  injured  by 
the  mental  disturbances  which  they  have  undergone,  and  who  therefore 
may  associate  their  more  or  less  constitutional  mental  condition  with  a 
neurasthenic  condition,  or,  in  other  words,  that  there  are  patients  who 
have  a  mixture  ;  we  have  seen  numerous  examples  of  such. 

It  is  no  less  certain  to  us  that  the  emotions  which  are  directly 
created  by  mental  disturbance  may  accentuate  and  reinforce  various 
psychasthenic  manifestations.     But  what  seems  to  us  the  most  impor- 


248     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

tant  element  of  distinction  is  that  the  obsessions,  the  phobias,  and  the 
doubts  of  the  psychasthenic  are  not  in  themselves  either  of  an  emotional 
origin  or  nature. 

We  know  that  psychiatrists  have  had  long  discussions  on  the  intel- 
lectual or  the  emotional  origin  of  obsessions.  It  seems  to  us  perfectly 
legitimate  to  distinguish  between  an  obsession  as  an  intellectual 
phenomenon,  and  a  preoccupation  which  is  a  phenomenon  of  emotional 
origin.  Now,  if  the  neurasthenic  has  preoccupations  he  does  not  have 
obsessions.  As  a  matter  of  fact,  the  neurasthenic  never  presents  those 
common  obsessions  of  the  psychasthenic  which  result  in  the  association 
of  flighty  ideas  which  contain  no  element  of  logic  but  which  persist  in 
the  patient's  consciousness.  Here,  for  example,  is  a  psychasthenic  who 
assipciates  psychiôally  some  idea  pertaining  to  her  food  or  her  toilet 
with  the  idea  of  death  for  herself  or  one  of  her  family.  Here  is  a 
doubting  man  who  has  given  himself  up  to  speculations  and  vain  ques- 
tionings. In  what  way  do  the  manifestations  presented  by  these  patients 
approach  those  that  we  have  observed  in  the  neurasthenic?  The  latter 
may  be  haunted  by  the  fear  of  death  or  the  fear  of  harming  some  one, 
or  he  may  become  fixed  upon  some  scruple.  But  all  these  preoccupa- 
tions are  frankly  emotional  in  their  origin  and  carry  in  themselves 
intrinsically,  and  not  only  consecutively  as  in  the  psychasthenic,  some 
emotional  element. 

The  psychasthenic  may  really  have  an  emotional  constitution,  which 
is  only  one  of  the  elements  of  his  general  psychological  inferiority. 
But  he  has  above  all  an  abnormal  mental  constitution,  while  the 
emotional  constitution  is  practically  in  a  general  sense  only  an  exag- 
geration of  a  normal  condition.  Psychasthenia  has  its  definite  place  on 
the  ladder  of  the  psychoses.    But  it  is  not  a  psychoneurosis. 

If,  now,  however,  we  glance  at  hysterical  manifestations,  it  will 
seem  as  though  we  ought  to  establish  a  few  more  distinctions.  To  tell 
the  truth,  there  is  only  one  which  seems  to  us  really  important,  and 
we  think  that  it  is  perhaps  pushing  matters  too  far  to  place  in  hysteria 
the  ensemble  of  phenomena  which  result  from  conscious  or  uncon- 
scious simulation.  Can  one  consider  those  patients  as  afflicted  with 
psychoneuroses  who  carry  their  really  sick  ideas  so  far  as  to  allow 
themselves  to  be  mutilated,  or  to  practise  self -mutilation  ?  These  pa- 
-tients  are  really  mental  cases;  they  are  mythomaniacs.  It  is  very 
evident  that  their  various  objective  organic  symptoms  spring  from 
mental  representations,  and  thus  offer  a  clinical  picture  which  closely 
approaches  that  of  hysterical  manifestations,  just  as  we  have  recently 
seen  that  our  exhausted  patients,  whether  they  were  or  were  not 
neurasthenics,  express  their  fatigue  by  the  same  subjective  impressions 
and  the  same  real  impossibilities.  But  here  again  there  is  an  element 
of  differentiation  which  must  be  sought  for  in  the  very  origin  of  the 
symptoms.     No  symptom  whose  origin  does  not  lie  in  some  emotional 


NEURASTHENIA  AND  HYSTERIA.  249 

traumatism,  and  which  has  no  relation  to  the  various  modes  of  physical 
emotion,  or  which  is  not  due  to  the  emotional  inhibition  of  a  certain 
number  of  mental  representations,  is,  to  our  way  of  thinking,  an 
hysterical  symptom.  That  there  may  be  associations  formed,  and  that 
the  mental  frailty  of  the  mythomaniac  predisposes  him  to  hysterical 
symptoms,  we  do  not  deny;  but  we  do  not  believe  that  mythomania  and 
hysteria  may  clinically  be  confused.  To  make  our  position  perfectly 
clear,  we  will  state  frankly  that  the  opinions  of  Babinski  on  hysteria 
refer  to  mythomania  and  not  to  hysteria,  and  th^t  in  no  possible  way 
could  we  confuse  it  with  this  latter  psychosis. 

Having  now  accomplished  our  work  of  disintegration,  we  feel  that 
we  caQ  pursue  our  study,  and  show  that  these  two  autonomous  psycho- 
neuroses,  hysteria  and  neurasthenia,  are  really,  in  themselves  and  in 
their  various  manifestations,  both  indisputably  morbid  entities. 


CHAPTER  XVI. 


HOW  ONE  BECOMES  NEURASTHENIC. 


The  first  factor  of  the  neurasthenic  state  whose  rôle  it  is  extremely 
important  to  define  is  emphatically  constitutional  predisposition.  First 
of  all,  are  there  individuals  who,  by  reason  of  their  constitution,  may 
unquestionably  be  regarded  as  being  liable  to  neurasthenic  attacks?  It 
seems  to  us  that,  although  certain  subjects  appear  to  be  better  armed, 
there  arenone  who  under  repeated  blows  might  not  succumb  sooner  or  later. 
We  have  seen  a  great  many  examples  of  patients  who  have  all  their  life 
shown  extraordinary  resistance,  who,  although  having  led  the  most  excit- 
able kind  of  hfe  that  one  could  imagine,  yet  had  always  maintained  com- 
plete mastery  over  themselves.  Yet  these  same  subjects,  when  attacked 
frequently  in  a  way  which  at  first  sight  might  appear  insignificant  in 
comparison  with  former  shocks,  nevertheless  become  depressed  or  very- 
emotional,  lose  their  intellectual  control,  and  sink  into  intensely  neuras- 
thenic states.  But  here  a  different  element  comes  in,  and  we  think  that, 
along  with  constitutional  predisposition,  other  elements  may  accidentally 
intervene  to  create  transiently  in  a  subject  an  affective  constitution  in 
such  a  way  that  he  may  become  neurasthenic.  In  other  words,  we 
think  that  no  neurasthenic  state  is  possible  without  a  peculiar  antecedent 
psychological  constitution.  On  the  other  hand,  we  are  quite  ready  to 
admit  that  this  psychological  make-up  may  be  either  constitutional  or 
accidental. 

What,  however,  are  the  elements  of  this  peculiar  constitutional  state  ? 
We  are  accustomed  to  saying,  and  it  is  a  very  true  expression,  that 
neurasthenia  springs  from  what  is  called  an  emotional  make-up.  Here 
we  must  stop  to  understand  the  value  of  this  term  and  to  distinguish 
its  characteristics.  That  the  neurasthenic  may  be  emotional  in  the 
physical  sense  of  this  word  is  a  thing  which  cannot  be  denied,  and  we 
have  already  indicated  our  way  of  looking  at  this  with  sufficient  dis- 
tinction. It  is  this  physical  emotional  constitution  which  dominates  the 
pathogeny  of  the  symptoms  of  the  psychoneuroses,  and  which  plays 
its  part  in  hysteria  or  neurasthenia.  It  is  by  the  necessary  existence 
of  this  antecedent  constitution  in  the  neurasthenic,  as  well  as  in  the 
hysteric,  that  we  are  sure  of  the  relationship  between  these  two  psycho- 
neuroses;  they  are  considered  by  others  as  autonomous,  because  with 
this  common  constitutional  element  are  associated,  either  in  the  hysteric 
or  the  neurasthenic,  additional  constitutional  elements,  which  latter 
are  peculiarly  different  according  as  they  are  considered  in  one  or  the 
other  of  these  diseases. 

The  thing  that  appears  to  us  to  characterize  the  peculiar  psycho- 

250 


HOW  ONE  BECOMES  NEUKASTHENIC.  251 

logical  constitution  of  the  neurasthenic  is  the  total  absence  of  the  power 
to  be  indifferent.  Question  a  patient  on  this  point.  He  will  tell  you 
that  he  has  always  taken  things  to  heart.  Although  in  the  domain  of 
pure  consciousness  he  may  be  capable  of  close  and  exact  reasoning,  yet, 
when  it  comes  to  the  application  of  everything  that  relates  properly 
speaking  to  life,  he  feels  more  strongly  than  he  reasons.  Everything  is 
personal  to  him.  He  thrills  to  excess,  he  responds  in  all  cases  much 
too  strongly  to  be  able  to  reflect  without  first  being  obliged  to  make  an 
effort  to  control  himself.  His  life  is  a  perpetual  struggle  between  his 
power  of  direction — or  his  will,  if  you  prefer  it — and  his  feelings.  Very 
generally,  however,  and  this  is  in  the  common  sense  of  the  word,  the 
candidate  for  neurasthenia  is  over-sentimental.  He  has  too  much  of 
what  we  are  accustomed  to  call  ''heart."  His  affections  are  too  strong, 
and  sometimes  a  little  jealous,  and  in  the  whole  domain  of  affectivity 
he  will  feel  special  susceptibility.  It  would  be  both  an  error  and  an 
injustice  to  tax  such  subjects  with  a  lack  of  will  and  faint-heartedness. 
They  often  have  as  much  and  even  more  courage  and  will  than  many 
others,  and,  in  reality,  there  are  hardly  any  but  those  who  have  a 
neurasthenic  constitution  who  really  accomplish  anything  in  life.  But 
if  he  has  this  quality  which  consists  in  taking  life  very  seriously,  the 
very  excess  of  this  quality  becomes  a  defect  in  him  and  a  danger  to 
be  avoided.  This  means  palpably  that  his  will,  however  vigorous  it 
may  be  considered  intrinsically,  is,  none  the  less,  often  put  to  tests 
which  are  too  great  and  too  frequently  repeated.  In  so  far  as  he  is 
sentimental,  he  has  a  manifest  tendency  to  play  a  passive  part  in  life, 
and  all  action  presupposes  a  preliminary  struggle  in  him  in  bringing 
his  will  into  play.  Action,  as  far  as  he  is  concerned,  is  not  an  in- 
stinctive and  almost  unreasoning  reaction.  It  is  the  result  of  the 
tension  of  his  whole  being  in  which  his  reasoning  will  comes  in  conflict 
with  his  feelings. 

Such  a  mental  constitution  is  a  long  way  removed  from  the  con- 
stitution of  a  psychasthenic.  The  latter  is  a  weakling  and  a  degenerate 
in  many  ways.  It  is  rare  for  him  to  sin  by  excess  of  sentimentality. 
It  is  enough,  in  order  to  understand  this,  to  call  to  mind  the  impres- 
sions made  upon  persons  who  have  come  in  contact  with  psychasthenic 
subjects  or  individuals  who  have  become  neurasthenic.  The  latter  have 
always  been  considered  by  those  who  lived  with  them  as  brave  people, 
perhaps  too  scrupulous  and  too  loyal,  but  possessing  the  power  to  attract 
strong,  firm  friendships  ;  the  former  have  given  the  impression  of  being 
selfish  and  indifferent,  and  incapable  of  arousing  any  sympathy.  The 
difference  is  recognized  even  by  the  physicians  who  care  for  these 
patients;  they  become  fond  of  the  neurasthenic,  but,  in  spite  of  all 
efforts  they  may  make,  it  is  rare  for  them  to  become  friendly  with 
psychasthenics.  Reciprocally,  the  neurasthenic  is  a  grateful  patient,  but 
one  cannot  always  say  as  much  for  the  psychasthenic. 


252  SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

This  leads  us  to  bring  out  into  relief  the  difference  which  dis- 
tinguishes the  constitution  of  the  emotions  and  affections  which  belongs 
and  has  always  belonged  to  the  neurasthenic,  from  the  constitution  of 
the  psychasthenic.  The  latter  may  be  of  an  emotional  nature;  that  is 
understood.  As  a  matter  of  fact,  he  generally  is.  Inversely,  the 
neurasthenic,  like  the  psychasthenic,  may  come  to  have,  but  more  or 
less  slowly,  phobias  and  obsessions.  But,  as  we  have  already  said, 
while  the  obsessions  and  phobias  of  the  psychasthenic  spring  from  some 
fault  of  the  mechanism,  a  fault  which  emotion  may  exaggerate,  but 
which  it  does  not  directly  create,  quite  the  reverse  is  true  of  the  neuras- 
thenic. The  latter  does  not  become  obsessed  in  the  true  sense  of  the 
word,  but,  rather,  preoccupied,  and  only  in  a  secondary  way.  When 
his  intellectual  control  or  his  will  has  become  deficient,  he  is  invaded  by 
impressions  and  sensations  which  he  cannot  prevent  from  becoming 
diffused  in  his  consciousness,  because  he  is  unable  to  get  hold  of  him- 
self. It  would  be  altogether  wrong  to  look  upon  the  neurasthenic  as 
having  the  mental  constitution  of  a  man  with  phobias  and  obsessions. 
And  likewise,  as  we  have  already  said,  it  does  not  seem  to  us  that  we 
could  consider  psychasthenia  as  a  peculiar  constitutional  form  of  neuras- 
thenia. The  future  neurasthenic  certainly  has  a  constitutional  pre- 
disposition, but  this  predisposition  differs  essentially  from  that  of  the 
psychasthenic  in  that  from  the  start  the  latter  is  already  sick,  while  at 
the  start  the  future  neurasthenic  has  only  one  fault,  that  of  having  an 
emotional  nature  accentuated  by  large-heartedness. 

It  is  beyond  all  doubt  that  a  manifest  exaggeration  of  emotionalism, 
allied  to  a  marked  development  of  affected  sentimentality,  though  not 
of  sentiment,  may  accidentally  break  out  in  certain  individuals  and  in 
this  way  favor  the  development  of  secondary  neurasthenic  states.  This 
is  all  the  more  apt  to  happen  in  subjects  who  are  organically  affected 
in  the  general  ensemble  of  their  psychic  faculty.  Although  exaggerated 
emotional  states  and  tearful  sentimentality  form  factors  of  these  con- 
ditions, there  are  very  frequently  associated  with  them  a  more  or  less 
marked  diminution  of  intelligence  and  an  almost  constant  lack  of  will 
power.  Such  processes  may  be  observed  either  as  episodes  or  in  a 
definite  way.  Here,  for  example,  is  a  man  fifty  years  of  age,  who 
previously  had  not  shown  any  of  the  constitutional  elements  which  one 
meets  in  future  neurasthenics,  but  who  nevertheless  presents  symptoms 
which  are  distinctly  superposable  to  those  of  neurasthenia.  However 
strongly  inclined  one  might  be  to  attribute  the  capital  rôle  to  the  psycho- 
logical elements  in  the  genesis  of  the  psychoneuroses,  it  would  be  wrong 
to  consider  such  a  patient  otherwise  than  one  presenting  mixed  symp- 
toms, functional  symptoms  in  relation  to  psychological  troubles  which 
in  themselves  are  of  organic  origin.  Arteriosclerosis  or  insufiicient 
renal  development,  etc.,  may  be  the  cause  of  it;  and  the  further  one 
advances  in  the  study  of  neuropaths  the  more  one  will  find  that,  if 


HOW  ONE  BECOMES  NEURASTHENIC.  253 

among  the  so-called  organics  there  are  a  great  many  functionals,  among 
the  nervous  or  those  who  pretend  to  be  such  there  are  also  many  who 
are  organically  afflicted.  But  in  so  far  as  the  psychic  defects  may  be 
constitutional  or  secondar>%  the  results  may  remain  the  same.  It  is 
none  the  less  true,  from  the  pathogenic  point  of  view,  as  well  as  from 
the  point  of  view  of  prognosis,  that  there  is  a  great  distinction  to  be 
made  between  true  neurasthenics  all  of  whose  symptoms  are  functional 
in  nature  and  those  patients  who  add  a  functional  symptomatology  to 
an  organic  symptomatology  which  often  has  every  chance  of  becoming 
aggravated  in  consequence. 

That  like  conditions  of  diffuse  psychologic  debility  may  be  produced 
as  the  result  of  serious  diseases  is  theoretically  possible.  Practically  it 
appears  to  us  quite  exceptional. 

What  is  more  curious  and  less  rare  is  a  diffuse  psychological  modifica- 
tion which  the  uprising  of  a  sudden  and  intense  emotion  may  cause 
in  an  individual.  We  have  seen  subjects  who  up  to  a  certain  time  had 
been  remarkably  resistant,  but  who,  when  caught  in  an  accident  or 
hurt  in  some  way  in  their  deepest  feelings,  underwent  a  change  no 
less  abrupt  and  intense  than  that  which  a  great  emotion  might  have 
caused.  Serious  neurasthenic  conditions  may  follow  and  be  developed 
as  a  result  of  troubles  thus  created.  Such  subjects,  who  up  to  that 
time  had  been  calm,  reasonable,  with  plenty  of  sang  froid,  sometimes 
even  rather  indifferent,  have  under  the  influence  of  emotion  become 
extremely  sensitive  and  emotional. 

But  the  peculiar  thing  about  all  these  conditions  is  the  simultaneous 
attack  upon  intellectual  control  and  the  will,  whereas  in  ordinary 
neurasthenia  we  have  to  do  with  subjects  who  have  always  been  emotional 
and  sentimental,  but  who  have  only  lost  control  over  themselves  after 
a  considerable  length  of  time  and  heroic  struggles.  The  self-control  in 
such  cases  of  neurasthenia  following  sudden  emotion  has  been  lost,  at 
the  same  time  that  the  character  of  the  subject  has  changed  in  the  way 
that  we  have  just  indicated. 

It  seems  to  us,  therefore,  that  there  is  something  peculiar  in  this, 
and  that  such  affections,  if  we  wish  to  preserve  neurasthenia  as  a 
pathological  entity,  ought  not  to  be  included  within  the  limits  of  our 
study. 

Let  us  now  study  our  candidate  for  neurasthenia  with  his  emotional, 
affective,  and  sentimental  constitution,  and  his  tendency  to  exaggerate 
and  magnify  things,  and  to  take  them,  as  we  have  just  said,  too  much 
to  heart,  and  watch  him  in  his  struggle  with  life.  When  and  how  will 
he  become  neurasthenic? 

It  is  evident  that  the  different  elements  which  we  have  studied  in 
the  preceding  pages  are  going  to  come  into  play,  and  that  his  chances 
of  becoming  neurasthenic  will  be  in  proportion  to  the  number  of 
emotional  shocks  which  he  will  experience,  and  the  number  of  attacks 


254  SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

upon  his  domain  of  peculiar  susceptibility,  and  to  the  duration  of  each 
of  his  emotional  preoccupations.  They  will  be,  on  the  other  hand,  in- 
versely proportional  to  the  degree  in  which  he  can  conserve  his  intel- 
lectual control  and  to  the  resistance  of  his  will.  Here  there  is  evidently 
a  whole  series  of  individual  variations,  and  in  the  mastery  of  self  in 
the  subject  who  is  constitutionally  predisposed  to  neurasthenia  one  may 
find  every  degree.  But  it  is  the  nature  of  one  who  is  predisposed  to 
be  possessed  of  a  limited  resistance.  No  one  who  is  predisposed  may 
ever  dare  say  that  he  will  never  become  a  neurasthenic;  every  chance 
is  in  favor  of  his  becoming  one  if  he  undergoes  any  emotional  excitement 
which  is  sufficiently  strong  and  which  lasts  long  enough. 

The  latter  seems  to  us  to  be  the  chief  factor  in  a  certain  number  of 
given  circumstances.  Here,  for  example,  is  a  subject  having  very  great 
preoccupations  concerning  himself,  which  have,  however,  never  made 
him  lose  his  mastery  over  himself.  Let  a  new  emotional  excitement 
come  into  play,  and  something  very  analogous  to  what  occurs  for  a 
stimulated  contraction  of  the  cardiac  muscle  will  then  happen  to 
voluntary  consciousness.  One  knows  that  the  muscle  during  its  whole 
period  of  contraction  does  not  react  to  any  excitation  by  a  new  con- 
traction. This  is  what  has  been  called  the  law  of  periodic  non-ex- 
citability of  the  heart.  The  same  thing  is  true  for  the  will  of  our 
subject,  which,  tense  at  the  time  when  some  new  emotional  excitation 
occurs,  is  incapable  of  opposing  this  new  excitation  by  a  new  contraction. 
One  can  see  then  that  under  the  influence  of  successive  and  different 
emotional  stimuli,  of  which  one  is  continuous  and  the  other  episodal, 
the  subject  who  has  resisted  the  former  will  become  incapable  of  reacting 
to  the  latter,  even  though  it  in  itself  may  be  of  mediocre  value.  It 
thus  happens  sometimes  that  even  a  slight  additional  emotional  strain 
is  enough  completely  to  upset  a  mentality  which  has  hitherto  been  re- 
sistant. This  helps  us  to  conceive  of  the  mechanism  of  the  action  of 
slight  emotional  stimuli  in  the  production  of  neurasthenia  in  those  in- 
dividuals whose  will  had  been  on  a  great  strain  for  other  reasons. 
This  fact  has  its  clinical  value,  because  one  is  often  astonished  to  see 
intense  neurasthenic  conditions  attributed  by  the  patients  to  very  slight 
emotional  causes. 

On  the  other  hand,  this  mechanism  is  comparatively  rare,  and  it 
generally  happens  that  life  is  quite  able  to  furnish  the  predisposed  with 
continuous  exciting  and  emotional  causes  which  are  abundantly  suffi- 
cient in- themselves  to  overthrow  the  subject  who  after  having  held  out 
for  a  greater  or  less  length  of  time  ends  by  finding  himself  completely 
overcome  and  dominated  by  some  emotional  cause. 

It  is  not  often  that  neurasthenic  states  make  regular  progress  from 
the  very  beginning.  Very  often,  on  the  contrary,  they  are  produced  in 
successive  attacks  occasioned  by  some  continuous  emotion.  The  subject 
will  steel  himself  not  to  feel  the  emotion  which  he  is  aware  is  gaining  a 


HOW  ONE  BECOMES  NEURASTHENIC.  255 

greater  and  greater  control  over  him.  But  the  duration  of  his  voluntary 
resistance  is  all  the  shorter  in  proportion  as  the  strain  has  been  harder 
to  bear  and  required  the  output  of  a  greater  effort.  Just  in  the  pro- 
portion that  the  emotional  stimuli  are  repeated,  so  does  the  difficulty 
of  getting  hold  of  himself  increase.  Finally,  the  individual  becomes 
incapable  of  reaction.  He  is  no  longer  master  of  himself.  His  intel- 
lectual control  has  weakened.  He  is  henceforth  potentially  ready  to 
show  all  the  psychic  or  physical  manifestations  of  neurasthenia.  He  is 
already  a  neurasthenic,  because  he  has  entered  into  that  condition  which 
corresponds  to  the  definition  which  we  have  given  of  neurasthenia, — 
namely,  the  whole  group  of  phenomena  which  result  from  the  non- 
adaptation  of  an  individual  to  some  emotional  cause,  and  the  struggle 
of  the  individual  toward  this  adaptation. 

It  goes  without  saying  that  the  moment  the  emotion,  if  it  be  of 
external  origin,  has  reached  the  point  where  it  dominates  the  patient's 
will  and  reason,  it  will  establish  itself  as  the  leader  of  internal  emotion. 

All  these  ideas  have  been  pointed  out  in  the  preceding  chapters. 
What  we  must  do  now,  starting  from  the  point  of  view  which  we  seem 
to  have  acquired,  is  to  show  how  the  various  classic  as  well  as  the  rarer 
symptoms  of  neurasthenic  states  have  become  established. 

It  generally  happens  that  a  physician  pays  very  little  attention  to 
the  mechanism  which  is  present  at  the  genesis  of  various  symptoms 
presented  by  neurasthenics.  This  is  because  he  more  usually  finds  him- 
self in  the  presence  of  patients  belonging  to  that  very  special  class  of 
those  whom  we  have  already  called  ''neurasthenics  who  have  arrived.'* 
These  latter  present  such  a  crowded  and  complex  symptomatology  that 
a  pathogeny  as  unequivocal  as  a  psychic  pathogeny  seems  very  difficult 
to  accept.  This  is  because  the  physician  very  rarely  sees  the  neuras- 
thenic at  the  beginning  of  his  affection.  In  fact,  the  subject  who  has 
some  real  cause  for  continuous  preoccupation  and  allows  his  mind  to 
become  invaded  by  emotion  is  already  virtually  and  even  actually  a 
neurasthenic.  He  does  not  consider  himself,  however,  as  a  sick  man 
yet,  and  only  goes  to  his  physician  some  time  later,  when  a  whole  series 
of  secondary  symptoms  have  appeared,  of  which  the  relation  of  cause 
and  effect  with  the  patient's  emotional  state  is  often  not  at  all  clear 
either  to  the  physician  or  the  patient.  The  whole  difficulty  then  consists 
in  finding  out  exactly  the  moment  of  the  onset  of  the  affection  which 
h£Ls  caused  it.  Before  frankly  becoming  a  neurasthenic  with  all  the 
classical  symptoms  of  a  psychoneurosis,  a  subject  may  have  been,  per- 
haps for  a  considerable  length  of  time,  in  a  state  of  unstable  equilibrium, 
so  much  so  that  often  he  does  not  date  his  disease  back  further  than  a 
few  months,  when  sometimes,  as  a  matter  of  fact,  if  he  had  included 
the  whole  series  of  phenomena,  he  would  have  gone  back  several  years. 

If  one  wants  to  classify  the  various  manifestations  presented  by 
neurasthenics,  then,  one  might  say  that  they  could  be  considered  thus: 


256     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

(1)  Phenomena  of  simple  emotional  fati^e  and  psychic  and  physical 
disturbances  in  direct  and  immediate  relation  to  emotional  excitation. 

(2)  By  reason  of  these  disturbances,  manifestations  due  to  auto- 
and  hetero-suggestion  by  deficient  and  disharmonie  attitudes. 

(3)  After  a  greater  or  less  length  of  time,  symptoms  of  all  kinds 
which  are  the  immediate  or  remote  results  of  functional  troubles 
previously  created. 

In  other  words,  we  will  say  plainly  that  every  neurasthenic  goes 
through  three  phases, — a  first  phase  of  simple  emotional  disturbance,  a 
second  phase  of  functional  disturbances,  and  a  third  phase  where  the 
various  consequences  of  the  general  invasion  of  the  organism  by  previous 
functional  disturbances  finally  appear.  It  is  very  evident  that  such 
a  division  is  somewhat  schematic,  and  that  in  this  succession  of  phenom- 
ena there  is  for  any  given  period  of  time  neither  the  coexistence  nor 
necessary  exclusion  of  disturbances  presented  during  the  preceding 
period,  and  it  is  just  on  this  account  that  we  find  the  extreme  variability 
of  the  symptomatology  presented  by  these  patients. 

Between  the  neurasthenic  at  the  start  of  his  disease,  and  the  neuras- 
thenic who  has  arrived,  and  the  individual  who  only  shows  certain 
traces  of  some  old  neurasthenic  condition,  there  may  be  every  possible 
type  of  transition. 

We  lay  it  down,  then,  as  a  general  rule,  that,  when  one  finds  that 
one  has  a  neurasthenic  to  treat  and  is  trying  to  interpret  his  symptoms, 
it  is  always  necessary  to  go  back  to  the  emotional  cause,  whether  one  has 
to  seek  it  ten,  fifteen,  or  twenty  years  before,  because  it  is  the  thing 
which  has  brought  about  the  whole  series  of  consecutive  manifestations 
presented  by  the  patient,  and,  although  the  time  of  their  development 
may  sometimes  be  very  short,  it  may  also  sometimes  be  very  long. 

Here,  for  example,  is  a  lady  fifty  years  of  age,  a  false  gastropath, 
considerably  emaciated,  who  says  that  she  has  been  sick  for  two  years. 
If  one  tries  to  find  some  emotional  cause  during  that  period  of  her 
existence,  one  will  discover  nothing.  In  her  case  one  has  to  go  back 
twenty  years.  As  a  matter  of  fact,  when  she  was  about  thirty  she  lost 
her  husband,  whom  she  had  loved  very  much.  At  that  time  she  was 
greatly  overcome  with  grief.  She  had  a  whole  series  of  functional 
disturbances,  particularly  emotional  anorexia  (this  was  the  immediate 
emotional  phenomenon).  From  that  time  she  has  never  grown  accus- 
tomed to  the  idea  of  her  husband's  death.  Her  emotionalism  has  be- 
come considerably  greater.  She  has  become  very  suggestible,  and  under 
some  accidental  influence  she  became  in  this  way  a  false  gastropath 
(a  phase  of  secondary  disturbance).  Finally,  by  not  eating  enough, 
she  grew  very  thin  and  weak  (the  later  phase).  Here  is  a  patient  who, 
presenting  formerly  a  whole  series  of  other  troubles,  appeared  at  first 
sight  as  a  comparatively  recent  neurasthenic.  In  reality,  psychologically 
speaking,  she  was  neurasthenic  from  the  day  when  under  the  influence 


HOW  ONE  BECOMES  NEURASTHENIC.    ,  257 

of  her  great  emotion  she  lost  the  full  control  of  her  will.  According  to 
our  way  of  thinking,  and  we  cannot  repeat  it  too  often,  one  is  neuras- 
thenic from  the  moment  and  during  the  time  that  the  reason  is  carried 
away  by  emotion.  One  may  or  may  not  have  symptoms  :  it  is  a  question 
of  surroundings,  previous  organization  of  life,  etc.  But  in  neuras- 
thenia, apart  from  the  initial  psychological  disturbances  which  are 
essential,  almost  everything,  if  not  everything,  is  accidental. 

Having  said  so  much,  let  us  take  a  patient  corresponding  to  the 
type  of  the  neurasthenic  who  has  ''arrived,"  of, which  we  have  just 
been  speaking, — a  physical  or  psychic  major  asthenic,  presenting 
functional  troubles  of  every  kind,  very  thin,  suffering  from  insomnia, 
having  headache  and  pains  in  the  back,  in  brief  an  ideal  patient,  present- 
ing a  complete  picture  of  the  excessive  symptomatology  of  severe 
neurasthenia, — and  let  us  see,  in  his  case,  how  and  by  what  mechanism 
all  these  phenomena  which  he  presents  have  succeeded  one  another. 

Question  him.  You  will  learn,  first  of  all,  that  he  has  always  been 
emotional  and  impressionable,  and  that  he  has  always  taken  things  too 
much  to  heart.  His  condition  dates  back  at  least  eighteen  months  or 
two  years.  This,  as  a  fact,  is  the  time  usually  required  for  such  a 
diffuse  symptomatology  to  be  developed.  At  that  time  a  great  pre- 
occupation came  into  his  life.  Let  us  put  it  that,  having  no  private 
means  and  being  burdened  with  a  family,  he  was  threatened  with  the 
loss  of  the  situation  by  which  he  supported  himself  and  those  depending 
upon  him.  His  wife  was  a  woman  of  rather  weak  character,  and  he 
could  find  no  one  on  whom  he  could  lean  or  from  whom  he  could  hope 
for  any  moral  support.  He  kept  his  worry  to  himself.  For  a  certain 
length  of  time  nothing  in  particular  happened,  he  was  able  to  continue 
his  work,  but  he  already  found  that  it  required  a  greater  effort  on  his 
part.  From  time  to  time  he  had  a  mental  panic.  He  lost  sight  of  his 
actual  duties,  and  dreamed  of  the  danger  which  was  threatening  him. 
His  sleep  became  broken,  often  disturbed  and  interspersed  with  night- 
mares which  would  express  at  night  the  anxiety  he  felt  during  the  day. 
By  degrees  his  emotional  condition  increased.  His  mental  panics  were 
more  frequent.  His  work  became  extremely  difficult  and  fatiguing, 
because  he  thought  more  and  more  of  the  subject  of  his  preoccupation 
and  because  he  found  it  more  and  more  difficult  to  keep  control  of 
himself.  The  least  noise  exasperated  him;  if  any  one  asked  him  a 
question  he  jumped.  His  insomnia  became  very  troublesome,  and  he 
would  sometimes  pass  whole  nights  without  sleeping. 

Physical  emotional  phenomena  of  every  kind  appeared.  Each  time 
that  he  thought  of  his  situation  he  felt  nauseated.  He  would  grow 
pale,  or  else  would  have  a  feeling  of  congestion  and  break  out  into 
perspiration.  Sometimes  he  would  have  an  attack  of  polyuria.  At 
the  table  he  felt  no  appetite  and  had  to  force  himself  to  eat.  He 
would  only  eat  because  he  knew  he  must. 
17 


258     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

It  is  hardly  necessary  to  say  that  such  a  struggle  against  an  invad- 
ing emotion  cannot  go  on  without  causing  a  very  appreciable  physical 
and  intellectual  fatigue,  expressing  itself  at  this  time  by  an  impression 
that  physical  and  intellectual  fatigue  is  much  more  rapidly  tiring  than 
it  should  be  normally.  At  this  epoch  brain  fatigue  may  appear,  which 
is  expressed  by  a  feeling  of  tension  or,  on  the  contrary,  of  cerebral 
emptiness.  These  are  the  very  impressions  that  a  healthy  subject  ex- 
periences after  a  too  prolonged  intellectual  work. 

Such  are,  very  briefly  outlined,  the  disturbances  that  our  patient 
will  show  in  the  first  phase.  They  may  be  summed  up  in  a  few  words  : 
physical  and  psychic  phenomena  directly  due  to  emotional  stimulation; 
phenomena  of  emotional  fatigue  and  real  fatigue,  due  to  the  excess  of 
work  which  the  constant  struggle  against  the  emotional  cause  imposes. 

This  situation  will  be  prolonged;  our  patient  is  going  to  go  on 
struggling;  he  will  put  forth  every  energy  to  keep  his  emotion  from 
completely  overwhelming  him.  Nevertheless,  he  has  perceived  that  in 
spite  of  all  his  efforts  his  work  is  not  so  well  done.  If  he  were  an 
accountant,  he  has  made  mistakes  in  his  figures;  if  he  had  clerical 
work,  he  has  forgotten  part  of  a  phrase  in  copying  a  letter.  He  has 
become  restless.  He  has  felt  as  though  he  were  going  mad,  and  has 
pictured  himself  incapable  of  work,  not  because  he  will  have  been 
dismissed,  but  because  he  really  feels  himself  incapable  on  account  of 
illness.  When  this  happens,  the  last  straw,  if  one  might  so  call  it,  has 
fallen  upon  our  patient,  who,  incapable  of  doing  anything  to  help  him- 
self, sinks  into  the  second  phase  of  his  illness.  It  is  quite  natural  that 
none  of  these  phenomena  which  have  hitherto  appeared  should  dis- 
appear on  this  account;  quite  the  contrary.  But  new  manifestations' 
are  going  to  appear.  They  will  result  from  a  double  mechanism  :  auto- 
observation  and  auto-  and  hetero-suggestion.  Our  patient,  whose  in- 
tellectual control  is  now  affected,  becomes  incapable  of  judging  his 
impressions  and  of  appreciating  his  various  sensations  in  their  true 
nature  and  origin. 

All  the  ideas,  which  his  cerebral  automatism  introduces  into  the 
field  of  consciousness,  are  preserved  and  ranked  on  the  same  plane.  The 
filter  of  his  voluntary  consciousness  is  out  of  order,  and  our  patient 
takes  for  a  fact  what  is  often  only  a  memory  which  has  been  in  some 
way  mechanically  evoked.  By  this  process  he  may  soon  acquire  phobias. 
The  idea  of  sudden  death  or  the  thought  of  suicide  will  flit  through 
his  mind.  These  ideas  seem  as  real  to  him  as  if  he  were  entertaining 
them  in  earnest.  He  has  a  fear  of  sudden  death,  and  a  dread  that  he 
will  want  to  commit  suicide.  He  is  afraid  of  doing  harm  to  somebody. 
There  are  no  ideas  of  this  kind  that  one  may  not  find,  and  which 
though  normally  fugitive  may  become  fixed  in  the  neurasthenic  because 
they  are  not  submitted  to  judgment.  These  phobic  manifestations  in 
themselves  become  factors  of  superadded  emotional  stimulation. 


HOW  ONE  BECOMES  NEURASTHENIC.  259 

All  intellectual  work  tires  him,  and  soon  it  is  impossible  for  him 
to  do  any  work.  His  memory  seems  to  be  failing,  because  to  call  it 
forth  from  such  a  disorganized  brain  is  evidently  very  difficult.  Our 
patient  even  pretends  that  his  intelligence  is  affected,  and  that  he 
cannot  understand  things  perfectly,  that  he  can  no  longer  follow  the 
line  of  thought  of  the  person  w^ho  is  speaking  or  the  author  he  is  reading. 
This  may  be  quite  possible:  for  he  is  perpetually  somewhere  else,  per- 
petually distracted  from  everything  that  is  going  on  around  him  by 
what  is  going  on  within  him.  He  is  continually,  absorbed  in  his  own 
condition. 

Does  he  attribute  all  the  symptoms  which  he  feels  to  their  true 
cause, — viz.,  his  emotional  preoccupation  ?  Very  rarely.  But  this  seems 
quite  natural,  because  in  such  a  patient  his  causal  emotional  pre- 
occupation has  already  become  merged  in  a  large  group  of  superadded 
phenomena.  Physically  and  intellectually  he  grows  weak;  and  it  is 
then  that  he  will  say  that  he  is  sick.  Now  our  patient  will  begin  to 
watch  and  examine  himself.  Naturally  he  will  experience  various  sen- 
sations which  will  be  those  resulting  directly  from  emotional  stimulation. 

We  have  already  spoken  above  of  the  peculiar  orientation  taken  by 
emotional  stimuli  according  to  the  particular  case.  We  have  said  that 
normal  individuals  react  somatically  in  various  ways  to  emotion.  In 
some  it  is  the  stomach  which  is  upset;  among  others  there  is  a  certain 
disagreeable  sensation  which  appears  in  the  perineum  or  bladder.  In 
still  others  emotion  brings  on  palpitation  of  the  heart,  diarrhœa,  or 
polyuria,  and  another  will  feel  his  legs  give  way  beneath  him.  What- 
ever the  subject  may  have  felt,  the  memory  of  these  sensations  will 
remain.  If  he  does  not  experience  them  again,  he  will  have  auto-sug- 
gestions about  the  sensations  which  he  is  going  to  experience,  and,  as  a 
matter  of  fact,  it  is  the  particular  fixation  which  he  is  most  apt  to 
have  which  will  bring  about  physical  reaction  consecutive  to  the  emotion 
on  which  our  patient's  auto-observation  will  become  centred.  He  will 
have  auto-suggestions  about  his  stomach,  or  his  intestines,  or  his  heart, 
or  his  lungs,  or  his  urinary  duct.  He  will  imagine  himself  afflicted  with 
some  mental  or  spinal  disease.  He  will  picture  himself  having  heart 
trouble,  or  tuberculosis,  or  dyspepsia,  or  enterocolitis,  etc.  He  may 
believe  that  he  can  have  all  of  these  at  the  same  time.  Now,  if  he 
begins  to  read  and  converse  upon  the  subject  and  gather  that  little 
knowledge  which  is  a  dangerous  thing,  or,  above  all,  if  some  physician 
turns  his  thoughts  in  an  unhealthy  direction,  our  subject,  who  often  has 
at  first  had  a  little  fear  of  everything,  will  now  definitely  fix  his  fears 
upon  such  or  such  an  organ,  which  will  become  for  him  the  centre  of 
divergence  for  all  the  troubles  he  feels. 

Thus  by  self-observation  and  self-  and  outside-suggestion  our  pa- 
tient will  manage  to  have  one  or  several  bodily  fixations.  But  here 
we  must  understand  exactly  what  we  mean  by  functional  trouble.    We 


260     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

have  designated  under  this  name  the  group  of  phenomena  which  may 
occur  from  the  intervention  of  the  psychism  interfering  with  automatic 
normal  functions.  But  does  this  mean  that  the  troubles  which  are 
felt  by  our  patient  have  no  objective  reality,  that  in  a  word  they  may 
be  imaginary  troubles?  By  no  means,  for  our  patient  suffers  exactly 
as  much  as  if  he  had  real  organic  troubles.  The  difference  between  what 
he  experiences  subjectively  and  what  an  individual  who  has  real  lesions 
experiences  is  purely  a  question  of  pathology.  The  tachycardia,  or 
dysuria,  or  impotence,  or  gastro-intestinal  atony  which  psychic  impres- 
sions have  created  is  by  no  means  imaginary  on  that  account.  The 
subject  really  has  palpitations  and  difficulty  in  urinating,  or  more  or 
less  complete  genital  insufficiency,  or  digestive  troubles,  just  exactly  as 
if  he  had  exophthalmic  goitre,  or  a  stricture,  or  a  castration, — just  as 
if  he  had  a  cancer  of  the  stomach,  for  example.  The  disturbance  is  no 
less  real  for  being  of  psychic,  suggestive,  or  emotional  origin. 

But  outside  of  the  direct  action  exercised  by  a  psychical  stimulus, 
which  may  itself  be  either  exciting  or  inhibitory,  on  the  function,  other 
troubles  occur  which  spring  from  a  very  peculiar  mechanism  which  we 
have  already  described  in  the  first  part  of  this  work.  We  allude  to  the 
disturbances  due  to  disharmony.  These  are  all  troubles  which  result 
directly  by  the  intervention  of  attention  in  the  production  of  acts  which 
are  customarily  automatic.  We  have  seen  this  mechanism  come  in  in 
the  production  of  respiratory  troubles,  and  in  the  disturbances  of  diges- 
tion and  sleep.  We  have  seen  it  play  a  considerable  rôle  in  the  pro- 
duction of  the  physical  asthenia  of  the  neurasthenic  and  of  all  those 
distressing  fatigue  sjonptoms  of  which  they  so  often  complain.  We 
need  not  refer  to  them  again. 

There  still  remains  a  whole  series  of  morbid  manifestations  of  a 
more  exclusively  psychic  nature.  We  mean  "fixed  memories."  It  may 
be  an  impression  of  anguish  which  sometimes  has  been  fixed  for  a  very 
long  time  under  the  form  of  a  pain.  It  may  be  the  memory  of  fatigue, 
which  prolongs  an  impression  of  helplessness  which  the  subject  cannot 
make  up  his  mind  to  throw  off.  This  is  the  process  which  often  en- 
courages neurasthenics  to  retain  symptoms  which  at  a  given  time  might 
have  remained  isolated  without  any  other  added  phenomenon. 

In  short,  our  patient,  by  the  various  mechanisms  which  we  have 
examined,  has  become,  let  us  say,  a  major  neurasthenic,  presenting  a 
whole  series  of  functional  troubles.  He  has  now  reached  the  second 
stage  of  his  affection. 

He  may  pass  on  to  a  third  phase,  to  that  in  which  he  begins  to 
feel  all  the  consequences  of  the  functional  disturbances  "which  he  has 
hitherto  presented.  If  anorexic  or  dyspeptic,  he  has  probably  cut  down 
his  food  so  much  that  a  considerable  loss  of  weight  will  have  followed, 
bringing  with  it  general  depression  and  having  a  very  great  effect  upon 
his  bodily  health.     Let  this  condition  persist  for  a  long  time,  and  he 


HOW  ONE  BECOMES  NEUKASTHENIC.       261 

will  very  naturally  become  less  resistant  to  and  more  liable  to  contract 
an  infection  ;  particularly  will  lie  be  liable  to  acquire  a  tuberculosis. 

It  does  not  seem  to  us,  on  the  other  hand,  to  be  anywhere  proven 
that  a  functional  trouble,  though  it  be  of  purely  psychic  origin,  may 
not  in  the  long  run  create  true  organic  lesions.  And  when  the  authors 
of  former  days  included  emotional  causes  in  the  etiology  of  a  certain 
number  of  chronic  affections,  they  perhaps  expressed  a  truth  which  our 
too  material  age  has  done  wrong  to  scorn.  The  saying  **It  was  grief  or 
his  troubles  which  killed  him"  seems  to  us  to  have -something  more  in.it 
than  a  simple  popular  fiction. 

At  this  period  our  patient  might  sometimes  be  a  ** mixed  case,''  pre- 
senting still  a  whole  series  of  functional  manifestations,  but  also  offering 
for  our  consideration  certain  symptoms  which  had  slowly  come  to  pass 
from  organic  modifications  which  the  functional  troubles  had  created. 
But  if  this  were  so,  it  would,  as  a  rule,  be  rather  rare. 

Let  us  sum  up,  and  we  shall  see  that  our  patient  by  a  rigorous  chain 
of  events,  and  starting  from  the  single  point  of  departure, — an  over- 
whelming emotional  preoccupation,  with  the  loss  of  intellectual  control, 
— must  necessarily  present  all  the  phenomena  which  form  the  classical 
symptoms  of  neurasthenia. 

Is  there  in  this  affection  a  single  manifestation — ^we  say,  a  single  one 
only — which  can  seem  to  escape  from  the  pathogenic  mechanism  which 
we  have  just  developed  ?  We  do  not  believe  so.  It  wiU  be  enough,  how- 
ever, to  refer  to  the  first  part  of  this  work,  where  as  we  described  each 
of  the  functional  manifestations  we  have  attempted  to  bring  out  its  par- 
ticular pathogeny.  Emotion,  auto-observation,  and  auto-  and  hetero-sug- 
gestion,the  production  of  functional  troubles,  sometimes  the  possibility  of  a 
later  organic  association — ^this  is  the  whole  history  of  a  neurasthenic  ;  and, 
if  neurasthenia  appears  to  be  such  a  polymorphous  affection,  it  is  partly 
because  one  may  see  it  in  every  period  of  its  evolution,  and  also  because 
the  diversity  of  sjTnptoms  presented  is  due  to  the  multiplicity  of  possible 
psychic  orientations. 

It  is  also  true,  that,  although  the  symptomatology  of  a  neurasthenic 
may  sometimes  be  extremely  complex,  it  may  also  in  certain  cases  be 
relatively  simple,  and  be  limited  to  functional  troubles  in  a  given  organic 
system.  In  this  latter  case  it  is  generally  a  question  less  of  neurasthenia, 
properly  so  called,  than  of  lingering  neurasthenic  conditions.  These  are 
manifestations  which  have  continued  to  develop  on  their  own  account 
when,  the  emotional  cause  having  disappeared,  and  the  subject  having 
regained  his  intellectual  control,  there  still  persists,  concerning  some 
organ  or  function,  such  a  conviction  of  helplessness,  strengthened  by 
the  accumulation  of  self-  and  outside-suggestions,  that  the  disturbances 
persist,  even  when  the  cause  which  originally  created  them  has  dis- 
appeared. 

Thus,  we  may  see  people  who  continue  to  be  false  gastropaths,  false 


262     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

urinaries,  false  cardiacs,  and  false  genitals,  etc.,  for  a  considerable  length 
of  time  after  the  occurrence  of  emotional  cause.  Their  minds  are  sound, 
their  emotionalism  is  not  really  exaggerated,  their  intellectual  control  is 
normal  for  all  that  does  not  concern  the  functional  trouble  in  question  ; 
but  it  is  only  necessary  to  question  them  to  discover  the  emotional  cause, 
and  to  realize  that  at  a  certain  time  they  had  lost  their  self-control,  and 
it  was  on  that  account  that  a  purely  functional  affection  had  the  chance 
to  develop  in  them. 

However  precise  and  localized  the  actual  symptomatology  of  all  such 
patients  may  be,  they  deserve  just  as  much  to  be  included  in  the  picture 
of  neurasthenia.  Although  it  is  with  great  difficulty,  on  account  of  the 
variability  of  its  symptoms  and  symptomatic  entity,  that  we  can  define 
this  disease,  nevertheless,  it  seems  to  us  to  have  an  absolute  pathogenic 
autonomy.  There  is  not  one  of  the  phenomena  which  neurasthenics  may 
present  which,  either  directly  or  by  the  intermediary  stages  which  we 
have  described,  does  not  spring  from  the  insufficient  adaptation  of  the 
individual  to  some  emotional  cause,  and  from  his  struggle  to  adapt  him- 
self to  it.  Insufficient  adaptation  of  an  individual  to  an  emotion  gives 
us  all  the  phenomena  which  result  from  loss  of  intellectual  control  which 
is  the  specific  basis  of  neurasthenia  ;  and  the  struggle  for  this  adaptation 
gives  us  all  the  symptoms  bearing  upon  the  disordered  attempts  made 
by  the  subject  to  get  hold  of  himself  and  to  prevent  the  various 
functional  manifestations  which  he  presents.  We  cannot,  therefore, 
speak  of  neurasthenic  conditions.  There  is  no  such  thing  as  digestive, 
sexual,  or  urinary  neurasthenia,  etc.  Neurasthenia  is  an  entity,  and  if, 
like  any  other  disease,  by  disturbances  which  are  more  limited  in  a  given 
region,  it  may  take  on  certain  aspects  and  peculiar  forms,  it  has  pre- 
served none  the  less  its  full  and  complete  autonomy. 


CHAPTER  XVII. 

GENERAL    CONCEPTIONS    OF    HYSTERICAL    SYMPTOMS. 

When,  in  the  preceding  pages,  we  set  forth  our  general  conception 
of  neurasthenia  and  its  symptoms,  we  were  led  to  see  that  neurasthenia 
hardly  ever  develops  except  in  one  who  is  predisposed  to  it.  Is  the  same 
thing  true  of  hysteria  and  its  symptoms? — do  they  only  appear  in  sub- 
jects who  have  a  peculiar  mental  constitution,  or  what  we  might  call  a 
specific  constitution?  Before  we  answer  this  it  seems  to  us  that  we 
must  first  make  a  certain  number  of  distinctions. 

We  have  already  said  that  we  do  not  in  any  way  consider  that 
mythomaniacs  are  hysterics.  The  very  peculiar  mental  condition  of 
these  patients  should  not,  we  feel,  be  regarded  as  forming  a  constitutional 
predisposition  to  hysteria  and  its  symptoms.  What,  as  a  fact,  is  much 
more  constitutional  in  the  hysteric,  is  his  excessive  physical  emotionalism, 
and  again  the  very  pecuHar  action  of  that  emotion  upon  his  psychism. 
Hysteria  may  be  separated  into  two  broad  classes  of  symptoms.  On  the 
one  hand  there  are  all  those  which  belong  to  hysterical  attacks  and 
emotional  discharge,  while  on  the  other  hand  there  are  all  those  which 
either  abruptly  or  slowly,  but  always  following  some  emotion,  become 
established  in  a  way  which  is  generally  lasting,  and  unconnected  with 
any  attacks  properly  so  called. 

This  distinction  seems  to  us  to  be  of  importance,  because,  although 
certain  authors  consider  that  all  hysteria  expresses  itself  in  attacks,  we 
are  far  from  accepting  this  point  of  view.  We  frankly  say,  on  the 
other  hand,  that  the  attack  is  the  least  specific  thing  in  hysteria.  Be- 
tween an  emotional  syncope,  or  a  motor  agitation,  which  the  most  self- 
contained  individual  is  liable  to  feel  under  the  influence  of  some  great 
emotional  shock,  and  the  most  characteristic  hysterical  attacks  there 
exists  every  gradation.  There  are  some  subjects  who  have  a  single 
hysterical  attack  during  their  life  resulting  from  the  shock  of  some  great 
emotional  excitement.  Neither  before  this  attack  nor  ever  afterward 
have  they  presented,  nor  will  they  present,  any  hysterical  manifestation 
whatsoever.  In  short,  an  hysterical  attack  is  only  an  emotional  dis- 
charge. Under  the  influence  of  emotion  there  would  evidently  be  all  the 
more  chance  of  its  recurring,  because  the  subject  in  question  would  be 
more  emotional  than  usual.  But,  in  matters  of  nervous  attacks,  we  are 
not  at  all  convinced  that  there  is  anybody  who  is  absolutely  proof 
against  them.  There  are  some  people  for  whom  a  very  slight  emotion 
is  enough  to  start  off  an  attack.  There  are  others  who  only  react  in  the 
form  of  an  attack  when  they  are  under  excessive  emotional  stress. 

In  fact,  it  would  seem  that  from  this  point  of  view  there  is  no 

263 


264  SYNTHETIC  STUDY  OF  PSYCIIONEUROSES. 

qualitative  difference  in  the  subjects,  but  that  it  is  simply  a  question  of 
emotional  degree  which  varies  according  to  the  individual.  So  far,  and 
so  far  only,  can  one  admit,  as  far  as  hysterical  attacks  are  concerned, 
the  existence  of  individual  predispositions  which  characterizes  the  more 
intense  reaction  to  slight  emotional  excitement.  Naturally  it  must  be 
understood  that  we  are  not  thinking  now  of  people  who  like  theatrical 
effects,  and  who  at  the  slightest  annoyance  go  off  into  an  attack  of 
hysterics,  which  they  themselves  know  is  more  than  half  put  on.  These 
patients,  as  we  have  already  said,  are  mythomaniacs,  if  you  will,  but  not 
hysterics  in  the  very  special  sense  which  we  attach  to  this  term. 

The  same  thing  is  by  no  means  true  as  far  as  hysterical  accidents, 
properly  so  called,  are  concerned.  For  here,  on  the  other  hand,  we 
are  very  much  inclined  to  attribute  considerable  influence  to  the  peculiar 
mental  make-up  of  the  subject. 

First  of  all,  the  candidate  for  hysterical  symptoms  possesses  a  speci- 
ficity in  his  physical  emotional  reaction  to  a  greater  degree  than  the 
eventual  neurasthenic.  In  addition  to  the  fact  that  he  reacts  much 
more  intensely  to  an  emotional  stimulus,  which  is  sometimes  very  trivial, 
he  reacts  again  and  more  often  in  a  given  physical  region,  in  a  way  that 
is  almost  constant  for  a  given  subject,  whatever  may  be  the  emotion 
that  is  at  work.  That  hysteric  who  later  will  show  functional  paraplegia 
has  always  felt,  no  matter  what  may  be  the  emotion  that  she  is  ex- 
periencing, that  her  legs  were  giving  way  beneath  her.  This  other  has 
always  felt  her  emotional  reactions  expressed  by  a  sensation  of  weakness 
in  the  left  side.  Let  some  emotion  that  is  stronger  than  usual  over- 
whelm her,  and  she  will  become  an  hysterical  hémiplégie.  This  is  a  very 
frequent  phenomenon,  and  one  which  we  have  had  the  opportunity  of 
seeing  a  great  many  times  in  patients  having  hysterical  symptoms. 

What  is  even  much  more  characteristic  is  the  dissociating  action  of 
emotion  in  the  hysteric.  In  the  neurasthenic  an  emotional  stimulus  with 
the  physical  reaction  which  it  provokes  serves  as  a  starting-point  for 
some  psychic  fixation.  All  the  phenomena  which  follow  spring  from 
this  psychic  fixation  and  from  the  intervention  in  the  functioning  of 
the  organs  of  such  phenomena  as  observation  and  attention.  In  the 
hysteric  it  is  just  the  opposite  thing  which  occurs.  It  would  seem  as 
though  the  psychism  were  composed  of  badly  grouped  elements,  which 
emotional  excitement  is  capable  of  dissociating,  surrendering  an  organ 
or  a  functional  group  to  the  whim  of  the  will.  This  is  the  peculiar 
feature  in  the  general  mentality  of  hysterics.  They  are  unstable,  in- 
coordinated,  psychically  speaking,  in  a  degree  which  evidently  differs 
according  to  subjects,  but  is  always  quite  distinctly  marked.  Their 
mentality  has  been  compared,  and  not  without  reason,  to  that  of  a  child. 
Their  ideas  follow  one  another  but  never  take  root.  The  psychological 
mechanism  of  coordination,  ideas  of  time,  sequence,  and  causality,  are 
almost  foreign  to  them.     They  are,  if  we  might  use  the  expression, 


CONCEPTIONS  OF  HYSTERICAL  SYMPTOMS.  265 

*' badly  put  together."  As  a  matter  of  fact,  their  centres  of  mental 
representation  of  the  various  organic  functions  behave,  under  the  stress 
of  emotion,  as  if  they  were  quite  independent  of  one  another.  From 
this,  moreover,  arises  in  these  patients  the  very  great  specificity  of 
emotional  reactions,  and,  outside  of  all  symptoms  which  have  to  do  with 
attacks,  the  slight  degree  of  diffusion  and  localization  of  their  symptoms. 

All  these  symptoms  have  a  common  characteristic.  They  are 
phenomena  of  immobilization,  of  psychic  forgetfulness,  if  one  might 
so  call  them.  An  hysteric  who  becomes  paraplegic  acts  as  though  he 
has  forgotten  that  he  has  limbs.  In  the  same  way  an  hysterical 
hémiplégie  has  lost  the  mental  representations  which  correspond  to  a 
whole  half  of  her  body.  This  is  the  rule.  It  is,  however,  far  from  being 
absolute,  and  it  may  happen,  on  the  contrary,  that  a  new  representation 
brought  about  by  some  emotional  excitement  may  be  added  and  super- 
posed upon  the  previous  mental  representations.  Such  a  representation, 
without  any  struggle  on  the  part  of  the  subject,  without  his  having  even 
been  aware  of  it,  becomes  an  integral  part  of  his  mentality,  and  tends 
to  take  definite  part  in  it.  The  thing,  therefore,  that  characterizes  the 
constitutional  mentality  of  the  hysteric  is  his  absolute  passivity  concern- 
ing his  more  or  less  marked  defect  of  coordination. 

This  passivity  is  found  in  the  hysteric  once  the  symptom  has  been 
created.  While  the  neurasthenic  is  restless  and  preoccupied,  while  he  be- 
comes obsessed  concerning  his  symptoms  and  is  wholly  uneasy  about 
them,  nothing  of  the  sort  may  be  observed  in  the  hysteric.  Were  he 
quadriplegic,  it  would  make  no  difference  to  him.  This  indifference  of 
the  hysteric  concerning  his  symptoms  constitutes  a  very  peculiar  element 
in  this  class  oî  patients.  But  this  very  special  mentality  is  a  natural 
result  of  the  mechanism  of  dissociation  or  passive  disintegration  which 
was  present  when  his  symptom  arose.  The  paraplegic  hysteric  has  for- 
gotten in  some  fashion  that  he  ever  had  limbs.  He  no  longer  seems  to 
be  aware  that  he  has  any.  In  fact,  he  acts  as  if  he  never  had  had  any, 
and  as  if  he  had  never  known  what  it  was  to  walk.  The  same  observa- 
tions could  be  made  in  regard  to  hysterical  deafness,  amaurosis,  dumb- 
ness, and  contractures. 

Before  as  well  as  after  his  infirmity,  the  hysteric  is  in  no  way 
preoccupied  or  liable  to  obsessions.  In  that  again  he  differs  profoundly 
from  the  neurasthenic. 

This  mental  fragility,  this  lack  of  psychic  coherence,  this  passivity 
of  the  hysteric  make  it  evident  that  he  may  be  suggestible.  He  has  no 
power  to  keep  out  any  ideas  which,  by  the  mechanism  of  the  association 
of  ideas  and  memory,  his  psychological  automatism  introduces  into  his 
consciousness.  In  the  same  way  he  would  consider  as  real  the  ideas 
which  had  been  introduced  to  him  by  some  hetero-suggestion.  But  we 
must  make  some  reserves  on  this  point.  The  psychological  automatons 
who  have  served  as  objects  of  study  for  a  great  many  physicians  and 


266     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

some  psychologists  are,  almost  without  exception,  perfectly  at  home 
with  medical  observations,  and  naturally  are  subjects  who  have  had  a 
long  and  careful  education.  These  individuals  of  double  personality 
who  are  turn-about  automatons  or  conscious  beings  are  but  very  seldom 
met  by  the  most  experienced  physician  in  his  career. 

Concerning  suggestibility  during  hypnotic  sleep  we  have  nothing  to 
say.  We  belong  to  those  who  think  that  hypnotism  in  itself  is  a  method 
that  ought  not  to  be  employed.  Moreover,  does  not  hypnotic  sleep  con- 
tain, according  to  our  way  of  thinking,  something  specifically  hysterical  ? 
For,  looking  at  it  in  this  way  everybody  would  be  more  or  less  hysterical 
in  different  degrees.  We,  therefore,  only  wish  here  to  take  up  sug- 
gestibility in  a  waking  condition.  It  must  be  sufficiently  widespread  for 
certain  authors  to  try  to  base  their  doctrinal  theories  of  hysteria  on 
extreme  suggestibility.  One  cannot,  however,  make  any  nosological 
distinctions  among  neuropaths  on  the  ground  of  suggestibility.  Every 
being  is  more  or  less  suggestible  while  in  a  waking  condition,  and  that 
is  why  we  have  just  said  that  everybody  would  be  more  or  less  hysterical. 
The  neurasthenic  himself  is  still  much  more  auto-  and  hetero-suggestible 
than  the  hysteric,  but  the  mentality  is  wholly  different  in  these  two  cases. 
The  first  is  too  much  preoccupied  with  the  symptoms  with  which  he  is 
afflicted,  while  the  second,  on  the  contrary,  does  not  pay  enough  attention 
to  them. 

But,  on  the  other  hand,  one  cannot  by  suggestion  bring  up  at  will 
symptoms  in  hysterics,  any  more  than  one  can  at  will  cure  these  same 
symptoms.  Emotion  alone,  which  is  much  more  powerful  than  any  sug- 
gestion, is  capable  in  these  subjects,  predisposed  by  their  mentality,  of 
creating  symptoms  by  dissociation  or  by  addition  and  almost  certainly 
in  the  domain  previously  determined  by  the  emotional  specificity  of  the 
subject.  But  the  idea  that  one  can  create  such  symptoms  as  contractures 
and  paralyses,  without  provoking  emotional  states,  merely  by  mental  sug- 
gestion, in  a  domain  where  an  hysteric  has  never  been  previously  afflicted, 
seems  to  us  far  from  being  easy  to  grasp,  with  the  exception — it  must 
be  understood — of  the  mythomaniacs  and  the  specially  educated. 

It  is  no  less  true  that  in  the  persistence  of  certain  hysterical  symp- 
toms, in  the  continuity  of  dissociation  which  emotion  has  primitively 
produced,  we  would  very  willingly  admit  the  intervention  of  auto-sug- 
gestion, which  although  certainly  not  constant  is  nevertheless  frequent. 
Already  this  auto-suggestion  would  be  more  or  less  directly  created  by 
the  memory  of  the  emotional  cause  and  of  the  phenomena  felt  during 
the  action  of  the  emotional  shock.  If  the  hysteric  is  indifferent  to  the 
symptoms  which  he  presents,  it  must  also  be  true  that  he  is  insensible 
to  the  very  cause  which  has  determined  them,  and  it  is  by  this  inter- 
mediary that  a  suggestive  reinforcement  of  the  symptoms  may  some- 
times be  produced. 

In  the  great  majority  of  cases  the  hysterical  symptom  succeeds  the 


CONCEPTIONS  OF  HYSTERICAL  SYIVIPTOMS.  267 

emotional  shock.  This  emotion  may  act  in  two  different  ways:  it  may 
directly  create  a  symptom,  but  it  may  also  act  by  exaggerating  the  con- 
stitutional mental  predisposition  of  the  subject.  There  is  no  doubt  that 
an  extremely  lively  emotion  may  exercise  a  dissociating  aetion  on  the 
mentality,  and  that  in  a  very  large  measure  it  may  create  this  peculiar 
psychic  soil  on  which  the  hysterical  symptom  may  be  developed.  "We 
do  not  think,  however,  that  this  would  be  so  in  the  majority  of  cases, 
and  we  recognize,  as  a  matter  of  fact,  that  the  mental  predisposition  is 
more  often  constitutional  than  acquired. 

The  very  exagération,  in  comparison  with  the  normal  state  of 
emotional  susceptibility,  or  the  emotional  soil  if  one  prefers  it,  which 
constitutes  one  of  the  conditions  of  the  production  of  hysterical  symp- 
toms, may  in  itself  also  be  an  accidental  acquisition,  for  which  the  action 
of  lively  and  repeated  emotion,  or  even  simply  a  continued  emotional 
preoccupation,  is  responsible.  But  these  are  very  rare  cases,  and  it  is 
just  because,  by  reason  of  his  habitual  mentality,  although  the  hysteric 
reacts  sharply  to  external  emotional  shocks,  yet  he  hardly  ever  becomes 
emotionally  preoccupied  or  has  internal  emotions.  Cases  of  this  kind, 
nevertheless,  exist,  but  belong  rather  to  hysteroneurasthenics  than  to 
pure  hysteria. 

If  we  sum  up  what  has  gone  before,  we  would  say  then:  there  are 
subjects  who  are  more  readily  liable  to  become  hysteric  than  others  by 
virtue  of  their  emotional  as  well  as  their  mental  constitution,  which  is 
more  often  congenital,  but  which  may  also  often  be  acquired.  This 
mental  constitution  is  not  to  be  confounded  with  suggestibility  if,  how- 
ever, one  excludes  the  suggested  idea  which  is  strongly  reinforced  by 
emotion.  Finally,  the  individual  predisposition  by  the  particular  kind 
of  emotional  orientation  of  the  subject  may  in  a  great  degree  fix  the  seat 
of  the  ultimate  hysterical  symptom. 

But  in  the  genesis  of  an  hysterical  symptom  one  must  not  only  take 
into  account  the  personal  factors  of  the  subject  who  is  afflicted  with  the 
symptoms.  The  rôle  of  emotional  shock  in  the  localization  of  the 
hysterical  symptom  is  none  the  less  considerable.  A  woman  learns  sud- 
denly of  the  death  of  one  of  her  family,  and  experiences  some  un- 
pleasant sensation.  This  is  one  of  those  cases  where  in  the  simple 
localization  of  symptoms  there  will  be  brought  into  play  specific  in- 
dividual emotional  reactions.  If  the  emotional  shocks  are  expressed  at 
that  time  by  a  giving  way  of  the  limbs,  or  by  difficulty  in  speech,  or  by 
a  sensation  of  numbness  on  the  left  side,  the  subject  may  haves  a 
paraplegia  or  mutism  or  hemiansesthesia.  Here,  on  the  other  hand,  is  a 
woman  who  shows  a  contracture  of  the  right  arm,  which  came  on  sud- 
denly when  in  a  moment  of  anger  she  wanted  to  strike  her  husband. 
Here,  on  the  other  hand,  is  a  young  girl  the  adductors  of  whose  lower 
limbs  are  contracted.  This  contracture  followed  an  attempted  rape.  It 
is  evident  that  in  these  two  cases  it  was  the  very  nature  of  the  emotional 


268     SYNTHETIC  STUDY  OP  PSYCHONEUROSKS. 

traumatism  which  determined  the  seat  of  the  symptoms,  and  the  patient 
became  immobilized,  in  the  latter  cEise  in  a  position  of  defence  and  in 
the  former  in  a  position  of  attack.  When  under  other  circumstances  an 
hysterical  paralysis  is  located  in  the  limb  which  was  hurt  during  the 
traumatism,  we  would  again  have  a  case  where  the  very  nature  of  the 
shock  which  was  experienced  would  have  determined  the  seat  of  the 
hysterical  symptom.  There  is  then  a  second  factor  of  localization  of 
hysterical  symptoms  which  has  its  very  great  importance. 

Although  we  may  be  quite  unprepared  to  understand  the  why  and 
wherefore  of  the  specificity  of  individual  emotional  reactions,  we  can 
better  grasp  the  general  mode  of  action  of  the  emotional  cause.  It  is 
not  a  simple  thing  to  do.  It  is,  nevertheless,  a  feasible  thing,  while  re- 
maining always  within  the  domain  of  hypothesis. 

It  seems  to  us  it  is  by  bringing  together  a  sufficient  number  of  cases 
where  the  hysterical  symptom  immediately  succeeds  the  emotional  shock, 
that  one  can  most  easily  gain  an  idea  of  the  mechanism  which  has  been 
present  at  the  establishment  of  the  difficulties  which  our  patients  show. 
We  have  already  said  that  we  consider  hysterical  accidents  as  being  more 
often  phenomena  of  dissociation.  Now,  things  happen  exactly  as  if  the 
ensemble  which  is  formed  by  the  psychic  centre  and  the  member  or  the 
organ  which  depends  upon  it,  and  which  the  emotional  shock  has  dis- 
sociated from  general  consciousness,  continued  to  functionate  auton- 
omously, according  to  the  impulsion  felt  at  the  moment  when  the  disso- 
ciation was  established. 

This  is  a  rule  which  seems  to  us  to  be  applicable  not  only  to  symptoms 
whose  localization  is  due  to  some  peculiar  emotional  stimulus,  but  as 
well  to  those  which  owe  their  localization  ^to  individual  emotional 
specificity.    This  latter  is  a  still  more  mysterious  mechanism. 

Let  us  take  the  subject  who,  under  the  influence  of  some  emotion, 
feels  his  limbs  give  way  under  him  and  who  develops  a  paraplegia. 
Here  dissociation  has  taken  place;  the  lower  limbs  have  in  some  way 
escaped  from  the  voluntary  control  of  our  patient  when  they  were  under 
an  inhibiting  influence.     Thus  there  is  established  a  flaccid  paraplegia. 

Let  us,  on  the  other  hand,  consider  the  patient  who  has  had  an 
adduction  contracture  as  a  result  of  an  attempted  rape.  Her  limbs  were 
drawn  up  the  moment  they  experienced  the  motor  stimulus  of  defence. 
It  is  no  longer  a  paraplegia,  but  a  contracture  which  one  then  observes. 

The  same  process  of  reasoning,  it'  seems  to  us,  might  be  applied  to 
the  great  majority  of  hysterical  symptoms.  It  is  not  strictly  applicable 
to  trophic  or  cutaneous  disturbances.  These  can  be  explained  by  the 
continuity  of  vasomotor  or  trophoneurotic  action. 

It  is,  however,  very  true  that  this  is  really  merely  a  theory,  and  we 
do  not  pretend  to  lay  it  down  as  anything  else  but  an  hypothesis  which 
satisfies  the  mind. 

We  have  already  said  elsewhere  what  we  think  concerning  the  period 


CONCEPTIONS  OF  HYSTERICAL  SYMPTOMS.  269 

of  incubation  of  hysterical  sjonptoms.  We  have  shown  that  in  reality 
it  was  chiefly  a  period  of  emotional  incubation,  and  that  the  time  between 
did  not  represent  the  necessary  time  for  the  subject  to  adapt  himself  to 
a  given  hysterical  symptom,  but  rather  the  time  which  would  permit 
the  emotion  to  develop  and  extend  and  accentuate  its  action. 

As  to  the  systematization  even  of  hysterical  symptoms,  we  have 
already  indicated  elsewhere  that  it  took  place  according  to  the  scheme 
of  mental  representations,  and  it  follows  that,  long  before  having  been 
a  bulbar  phenomenon,  emotion  is  a  phenomenon  of  psychic  localization. 
The  great  majority  of  hysterical  symptoms,  particularly  the  anaesthesisB, 
contractures,  and  paralyses,  conform  to  a  topography  which  corresponds 
to  intellectual  acquisitions,  and  not  according  to  anatomical  or  functional 
localization.  It  is  not  the  region  of  the  nerve  or  a  spinal-cord  segment 
or  a  region  of  the  psychomotor  cortex  which  is  afflicted;  it  is  the  ter- 
ritory of  one  or  several  of  a  great  number  of  mental  representations. 
These  are,  for  example,  all  the  conscious  or  subconscious  idesis  which 
preside  over  the  movement  or  the  sensibility  of  a  part  of  a  limb,  or  a 
member,  or  half  of  the  body,  which  are  no  longer  capable  of  being  called 
forth,  or  which  no  longer  reach  the  field  of  general  consciousness,  be- 
cause, as  we  have  just  said,  there  has  been,  under  the  influence  of 
emotional  shock,  a  dissociation  or  exclusion  in  some  way  of  the  psychism 
of  the  subject  of  all  the  ideas  leading  to  the  zone  which  is  thus  afflicted. 
Emotion  acts,  in  fact,  as  suggestion  would  act  by  dissociation,  by  re- 
trenchment, and  by  exclusion.  There  is  nothing  extraordinary  in  stating 
that  the  hysterical  manifestations  may  act  objectively,  as  do  phenomena 
of  suggestion.  It  is  such  an  appearance  which,  we  feel,  has  permitted 
the  suggestion  theory  of  hysteria  to  be  established  with  some  appearance 
of  truth.  But,  although  the  effects  may  be  identical,  it  is  by  no  means 
legitimate  to  infer  that  they  spring  from  the  same  cause. 

It  may  happen  that  under  certain  circumstances  a  different  mechan- 
ism intervenes,  and  that,  by  reason  of  an  emotional  traumatism,  ideas 
springing  from  subconsciousness  and  the  psychological  automatism,  and 
brought  about  themselves  more  or  less  directly  by  emotional  shock, 
will  penetrate  and  invade  the  field  of  consciousness,  where,  not  being 
critically  judged  (as  the  subject  is,  at  the  time,  incapable  of  all  intel- 
lectual, control),  they  are  admitted.  The  symptom  is  thus  bom  by  the 
addition  to  the  previous  mentality  of  the  individual  of  a  new  idea  which 
has  not  been  judged,  and  will  follow  the  scheme  of  mental  representa- 
tions. Here  again  we  find  parallelism  with  certain  phenomena  of 
suggestion. 

But  in  one  case  or  the  other  the  hysterical  symptom  always  appears 
as  being  a  residue,  or  an  emotional  relic. 

However  this  may  be,  it  seems  to  us  that  the  domain  of  hysteria  may 
in  fact  be  limited  to  the  very  domain  of  physical  and  psychic  emotional 
reactions.    Everything  that  an  emotion  may  create  in  an  accidental  and 


270     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

transient  way  hysteria  may  accomplish  in  a  lasting  way.  This  is  a 
doctrine  which  we  already  have  had  occasion  to  formulate  during  the 
course  of  this  work,  and,  in  the  different  functional  manifestations  of 
an  hysterical  nature  that  we  have  had  occasion  to  take  up,  we  have 
tried  to  bring  out  the  value  of  such  a  delimitation  of  hysterical  symptoms. 

We  shall  not  linger  any  longer  on  this  necessarily  rather  theoretic 
chapter  of  the  general  conceptions  of  hysteric  symptoms.  Once  having 
laid  down  our  method,  we  have  already  had  a  great  many  opportunities 
to  develop  our  way  of  looking  at  it.  We  have  shown  that,  although  we 
admit  the  secondary  intervention  of  suggestion  in  the  persistence  of 
hysteric  symptoms,  it  does  not  play,  according  to  our  way  of  thinking, 
anything  more  than  an  infinitely  small  rôle,  if  any,  in  the  genesis  of 
these  symptoms. 

We  have  said,  and  repeated,  that  at  the  basis  of  hysteria  we  must 
place  emotional  shock  as  the  capital  and  almost  exclusive  pathogenic 
factor.  We  have  shown  how  much  confusion  results  from  classifying  as 
hysterics  those  patients  who  have  been  completely  changed  by  a  long- 
continued  education  or  training,  or  else  from  classifying  them  with 
mythomaniacs  whose  relationship  with  hysterics  seems  to  us  to  be  quite 
effaced. 

It  now  remains  for  us  to  complete  this  study  by  etiological  con- 
siderations on  the  relative  frequency  of  hysteria  in  men  and  women,  by 
the  nature  and  frequency  of  emotional  causes  capable  of  creating  the 
symptoms  with  which  we  have  been  interested.  All  these  questions  have 
been  so  frequently  and  completely  treated  by  so  many  authors  that  it 
seems  useless  to  dwell  on  them  anew.  Being  somewhat  in  haste  to 
arrive  at  the  practical  and  therapeutic  part  of  this  work,  we  think  we 
can  sum  up  all  that  has  gone  before  by  saying,  that,  just  as  in  general 
pathology  one  groups  under  a  single  term  all  the  troubles  which  spring 
from  the  same  pathogenic  cause,  in  the  same  way  in  neurology  it  seems 
to  us  quite  as  legitimate  to  study  under  the  common  term  psycho- 
neurosis  the  symptomatic  mechanisms  which  recognize  emotion  as  a 
general  and  immediate  pathogenic  factor. 

According  to  the  ground  on  which  the  seed  falls  emotion  will 
exercise  its  action.  Sometimes  it  is  neurasthenia  which  will  be  developed, 
and  sometimes  it  will  be  hysteria  with  all  its  symptoms  which  will 
manifest  itself. 

The  psychoneuroses  thus  have  a  common  pathogeny,  emotion.  But 
with  the  same  cause  very  different  effects  may  follow,  according  to 
individual  predisposition,  and,  although  there  may  be  an  autonomy  of 
the  psychoneuroses,  there  is  also  an  autonomy  of  two  types  which  they 
may  present  :  neurasthenia  and  hysteria  have  each  their  pathologic  entity. 
The  neurasthenic  and  the  hysteric  are  distinct  individuals  with  an 
utterly  different  development,  who  nevertheless  belong  to  the  same 
family. 


CHAPTER  XVIII. 

GENERAL  CONCEPTION  OF  FUNCTIONAL  MANIFESTATIONS. 

Before  finishing  the  second  part  of  our  work,  it  seems  to  us  that 
it  would  be  useful  to  define  clearly  our  conception  of  functional  mani- 
festations. In  general  medicine  they  describe  as  -functional  symptoms 
— and  one  studies  them  in  nearly  every  affection  along  with  local  and 
general  symptoms — all  the  disturbances,  taken  as  a  whole,  which  any 
lesion  whatsoever  may  occasion  in  the  functions  of  an  organ.  If,  for 
example,  we  were  considering  a  pyloric  stenosis  of  organic  nature,  the 
gastric  stasis  and  vomiting  which  would  follow  would  be  called  functional 
symptoms. 

From  all  that  we  have  said  before,  it  is  very  plainly  to  be  seen  that 
the  functional  manifestation  of  the  neuropath  has  no  single  point  of 
contact — apart  from  the  involvement  of  the  same  function — with  the 
functional  symptom  of  a  patient  who  has  some  organic  disease. 

To  express  it  in  a  provisional  definition  which  is  intended  to  be 
limited  simply  to  the  subject  of  our  w^ork,  we  have  considered  as 
functional  manifestations  the  ensemble  of  disturbances  and  persistent 
sjonptoms  of  which  neuropaths  complain  and  which  are  created  in  these 
patients  outside  of  all  antecedent  somatic  lesion. 

It   seems  to   us  that  we   are  now  sufficiently   prepared   to   define 

functional  manifestations  in  a  shorter,  fuller,  and  more  concise  manner. 

]  I  They  consist  of  all  disturbances  of  psychic  origin  which  are  liable  to 

j  affect  the  functions.     They  represent  all  psychic  actions  on  the  bodily 

j  organs. 

It  is  this  action  of  the  psychism  on  the  physical  which  is  generally 
very  badly  understood.  There  are  some  ideas  which  to  the  present 
medical  generation,  accustomed  to  organic  interpretations,  form  a  sort 
of  dead  line. 

One  will  readily  admit  that  in  certain  cases  a  symptomatology  may 
be  purely  subjective  ;  that  it  will  have  no  objective  foundation,  nor  any 
organic  reality.  But  in  such  cases  one  will  take  it  for  granted  that  the 
subjects  who  present  this  symptomatology  are  imaginary  invalids,  or 
hypochondriacs. 

One  will  readily  recognize,  on  the  other  hand,  that  there  are  such 
things  as  neuropathic  disturbances  in  an  organ  which  have  created  no 
organic  change  in  the  organ  in  question.  But  one  will  then  refer  the 
symptoms  in  question  to  some  disturbance  of  innervation.  The  spinal 
ganglia,  the  major  sympathetic  nervous  system  will  be  brought  into 
play;  one  will  explain  such  and  such  a  symptom  by  neuralgia  of  the 
solar  plexus,  or  of  the  coeliac  ganglion.    One  will  use  it  to  support  some 

271 


272     SYNTHETIC  STUDY  OF  PSYCHONEUROSES. 

doctrine  of  the  existence  of  painful  zones,  more  or  less  distinctly  super- 
posed on  the  sympathetic  regions  which  they  hold  to  be  afflicted.  And 
they  pay  no  attention  to  the  fact  that  by  the  intercalation  of  a  greater 
or  less  number  of  neurons  there  is  at  the  extremity  of  each  nerve-fibre 
a  psychic  cell  ;  that  this  may  be  modified  in  its  djniamism — though  this  is 
merely  a  word — or  that  it  may  be  subjected  to  some  alteration,  whatever 
it  may  be,  is  no  less  constant  than  the  fact  that  the  whole  nervous 
mechanism  on  which  it  depends,  but  which  is  also  dependent  on  it,  will 
suffer  in  its  functioning  and  with  it  the  organ  to  which  it  goes. 

Let  us  take  a  simple  phenomenon  like  pain.  It  is  noteworthy  that 
attention  increases  it  and  distraction  diminishes  it,  even  while  the 
organic  cause  of  the  suffering  remains  constant.  The  subjective  pain 
phenomenon  thus  appears  to  be  only  a  relation  between  the  degree  of 
physical  stimulus  and  the  degree  of  psychic  receptivity.  But  physical 
stimulus  is  not  even  necessary  to  produce  pain.  A  psychic  stimulus  is 
all  that  is  needed  by  the  common  mechanism  of  memory  and  by  the 
mediation  of  emotional  anguish,  which  is  responsible  for  so  many  local- 
ized pains,  for  an  impression  of  pain  to  be  produced  in  the  psychic 
centre,  and  for  the  periphery  to  become  hyper^esthetic,  because  then 
normal  sensation  is  perceived  as  pain. 

That,  on  the  other  hand,  there  exist  a  whole  series  of  psychosecretory, 
psychomotor,  and  psychotrophic  functional  disturbances  is  not  even 
open  to  question.  Such  are  admitted  to  be  facts,  especially  as  far  as 
the  digestive  functions  are  concerned.  What  necessity  is  there,  then, 
to  interpose,  between  a  peripheral  disturbance  of  an  organ  and  a  dis- 
turbance of  its  psychic  centre,  which  was  the  cause,  any  change  or 
modification  of  the  nervous  pathway  which  unites  the  centre  to  the 
peripheral  organ? 

In  nervous  pathology  the  idea  is  the  same  as  the  thing  itself,  from 
the  subjective  point  of  view,  and  in  a  very  large  degree  it  is  capable  of 
creating  it  objectively. 

In  the  same  way,  for  example,  when  we  set  forth  our  conception  of 
false  gastropathies  it  would  have  been  quite  inexact  for  us  to  say  that 
there  is  no  such  thing  as  dilatation  of  the  stomach  or  hyperchlorhydria, 
nor  hypochlorhydria,  etc.  ;  but  we  admit  that  an  individual  whose  mind 
is  psychically  fixed  upon  his  stomach  after  he  has  experienced  some 
inhibitions,  which  is  more  frequently  the  case,  or  becomes  very  excitable, 
is  liable,  as  a  result  of  his  psychical  impressions,  to  have  a  gastro-in- 
testinal atony,  with  great  dilatation  and  hypochlorhydria,  or,  on  the 
other  hand,  symptoms  of  secretory  stimulation  leading  to  hyperchlor- 
hydria. Study  the  false  intestinals,  the  false  cardiacs,  the  false  pul- 
monaries,  etc.,  and  phenomena  of  the  same  kind  will  be  found.  It  is 
not  the  objective  reality  of  the  symptoms  presented  by  the  patient  that 
we  are  contesting  ;  it  is  the  belief  in  their  peripheral  origin. 

"We  have  seen  elsewhere,  that,  in  certain  cases  following  functional 


CONCEPTION  OF  FUNCTIONAL  MANIFESTATIONS.       273 

troubles,  organic  affections  would  start  up  which  were  directly  caused 
by  them.  In  this  we  have  the  very  proof  that  we  cannot  in  any  degree 
confound  a  functional  manifestation  with  a  purely  and  simply  imaginary 
phenomenon.  We  think,  in  other  words,  that,  in  the  harmony  which 
tends  to  establish  itself  between  the  mental  representa^tion  and  the  periph- 
eral condition,  if  the  mental  representation  is  primary  the  peripheral 
disturbance  will  be  secondary. 

Such  a  conception  is  by  no  means  a  pure  figment  of  the  mind.  It 
is  admitted  by  everybody  as  far  as  the  gastric  secretion,  for  example,  is 
concerned.  It  is  the  very  basis  of  the  normal  functioning  of  the  sexual 
organs.  The  extension  which  we  have  given  to  it  seems  to  us  to  be 
entirely  legitimate.  As  the  facts  oblige  us  to  admit  that  a  psychic 
modification  is  capable  of  modifying  the  functioning  of  given  organs, 
we  really  do  not  see,  then,,  how  in  the  relations  between  the  psychism 
and  the  organic  functions  one  could  strictly  limit  to  certain  functions 
what  from  all  evidence  must  be  a  general  law. 

Therefore,  a^fimptional  inanifestation  is  characterized  by  an  ante- 
cedent psychic  distnrbflTinp,  hnt  also  by  consecutive  peripheral  dis- 
turbances. 

This  idea  is  of  the  greatest  therapeutic  importance.  But  here,  even 
those  authors  who  admit  the  primary  psychical  nature  of  functional 
manifestations  are  divided  into  two  schpols.  One  wishes  the  patients  to 
be  treated  in  a  bilateral  manner, — ^that  is  to  say,  for  the  peripheral  dis- 
turbances which  they  present  and  for  the  psychical  condition  which  is 
the  cause  of  them.  The  other,  for  very  definite  reasons,  thinks  that  a 
psychic  pathogeny  requires  an  equally  psychic  therapy.  And  this  brings 
us  directly  to  the  third  and  last  part  of  our  work,  where  we  shall  take  up 
the  question  of  treatment,  and  in  particular  the  psychotherapy  of  the 
psychoneuroses. 


18 


THIRD  PART 

The  Treatment  of  the  Psychoneuroses. 
Psychotherapy  and  its  Adjuvant  Processes. 


CHAPTER  XIX. 

CRITICAL  STUDY  OF  THE  TREATMENT  OF  THE  PSYCHONEUROSES. 

There  has  been  a  marvellous  evolution  in  therapeutics  during  the 
last  few  years.  From  being  symptomatic,  as  it  used  to  be,  there  is  a 
greater  and  greater  tendency  for  it  to  become  pathogenic.  Medicine  no 
longer  attacks  the  symptom,  which,  considered  in  itself,  has  only  a  slight 
indicative  value.  It  concerns  itself  only  with  the  actual  causes  of  the 
disturbances  which  it  has  to  treat.  Specific  treatments,  like  that  for 
syphilis  or  malaria,  by  mercury  or  quinine;  specific  treatments  such 
as  serotherapy,  and  specific  treatments  such  as  psychotherapy,  which 
in  the  presence  of  affections  of  psychic  origin  essays  to  cure  them  by 
psychic  action.  In  short,  as  medicine  progresses,  one  sees  more  and  more 
that  very  Uttle  of  the  old  therapeutic  arsenal  remains,  except  those 
remedies  which  were  specific  without  the  fact  having  been  known. 
This  is  still  the  case  for  mercury  and  quinine. 

That  is  to  say,  that  in  our  conception  of  the  psychoneuroses  we  see 
no  place  for  drug  therapy.  That  it  may  from  time  to  time  find  some 
indication  in  an  added  phenomenon  not  depending  on  psychical  causes 
is  possible  ;  that  sometimes  one  may  help  a  patient,  or  at  least  be  able  to 
palliate  his  symptoms,  by  means  of  medication  may  also  happen;  but 
the  time  has  passed  when  one  could  pretend  to  do  a  good  piece  of 
medical  work  by  saturating  an  hysteric  or  neurasthenic  with  bromide  or 
phosphorus.  This  therapy  has  lived  its  day,  and  we  feel  that  it  is  time 
to  condemn  it,  without  any  circumlocution  or  restriction. 

Naturally,  it  will  always  be  more  easy  for  a  physician  to  give  a  pa- 
tient a  prescription,  with  the  therapeutic  conclusions  which  such  prac- 
tices lead  to,  than  to  draw  forth  clearly  the  psychic  or  moral  cause  of  the 
disturbances  presented  by  him.  Of  course  there  are  patients  who,  if 
they  leave  a  physician  without  having  managed  to  get  a  prescription 
or  a  new  régime  out  of  him,  will  imagine  that  their  consultation  has 
been  worth  nothing.  But  if  we  are  not  mistaken,  a  very  distinct  evolution 
has  begun  which  has  reached  even  the  great  public  who  are  sick.  They 
are  beginning  every^^^here  to  grasp  the  idea  that  functional  diseases  may 
be  treated  psychically.  If  there  are  really  still  a  great  number  of 
274 


STUDY  OF  TREATMENT  OF  PSYCHONEUROSES.       275 

neuropaths  whose  tendency  is  to  run  after  the  honeyed  words  of  a 
mesmerizer,  or  even  the  conjurer  of  the  neighborhood  or  of  their  city, 
we  are  convinced  that  it  will  not  be  very  long  before  all  nervous  patients 
will  demand  from  every  physician  whether  he  knows  how  to  treat  them 
by  psychotherapy. 

It  is  understood  that  drug  therapy  may,  in  a  certain  measure,  be  con- 
sidered as  psychic  therapy,  but  in  the  wrong  sense  of  the  word;  and 
many  physicians,  even  among  those  who  are  persuaded  of  the  real 
psychic  origin  of  the  psychoneuroses,  lenû  themselves  to  this  practice. 

It  will  help,  they  say,  if  only  through  suggestion.  Whether  you 
order  bromides  or  glycerophosphates,  or  whether,  graced  by  a  more  or 
less  high-sounding  Greek  or  Latin  name,  you  prescribe  pills  of  bread 
crumbs  or  dandelion,  you  are  acting  exactly  the  same  way.  If  you 
manage  to  convince  your  patient  that  the  medicine  prescribed  will  do 
him  good,  there  is  a  very  good  chance  that  this  will  be  the  fact,  and, 
although  you  have  chosen  an  indirect  method  of  medication,  you  will 
succeed  in  improving  his  condition. 

Nevertheless,  such  practices  seem  to  us  to  be  wholly  without  value. 
First  of  all,  we  hold  that  one  has  no  right  to  deceive  patients  and  abuse 
their  credulity.  On  the  other  hand,  although  the  medicines  may  be 
sufficiently  suggestive,  they  cannot  help  but  cost  money.  This  incon- 
venience is  trifling,  one  will  say.  Perhaps  so  ;  still,  one  should  not  for- 
get that  there  are  certain  neuroses  among  the  poorer  classes  as  well  as 
among  the  rich,  and,  when  by  the  aid  of  a  great  many  medicines  and  of 
repeated  prescriptions  you  have  successively  '  '  ameliorated  '  '  all  the  symp- 
toms presented  by  your  patient,  you  will  find  him  more  profoundly 
neurasthenic  than  ever,  because,  being  incapable  of  work,  he  will  have 
practised  the  strictest  economy  in  order  to  buy  drugs.  We  see  too  many 
of  these  heart-breaking  examples  in  the  hospital  clientele.  But  even 
with  the  rich  patients  the  method  is  equally  dangerous  and  quite  as 
inefficacious. 

By  medication  you  may  ameliorate  the  gastric  or  intestinal  conditions. 
Your  patient  will  complain  less  of  his  head,  or  of  his  kidneys,  or  his  legs, 
or  his  asthenia;  he  will  carry  about  with  him  a  whole  series  of  little 
vials  for  some  specific  suggestive  action.  He  will  keep,  carefully  locked 
in  a  cabinet,  powders  which  will  cure  headache,  others  that  will  help  his 
digestion,  others  that  will  make  him  sleep  sooner,  and  often  he  will  not 
hesitate  to  have  himself  subcutaneously  injected  every  month  with 
various  tonics  that  will  have  the  same  effect  upon  him  as  a  whip  upon  a 
tired  horse. 

The  suggestive  action  of  medication  is,  however,  supposed  to  be 
going  on  all  this  time  ;  and  the  physician  will  feel  triumphant  when,  on 
asking  his  patient,  **Well,  how  is  your  stomach  acting  now?  how  are 
your  kidneys?  are  you  sleeping  any  better? '*  etc.,  and  the  latter  will 
reply,  '* Doctor,  it  seems  to  me  that  I  am  a  little  better  in  that  way.** 


276      THE  TREATMENT  OF  PSYCHONEUROSES. 

Things  will  go  on  better,  in  fact,  until  some  day  the  patient  will  per- 
ceive that,  although  he  is  a  little  better  in  each  successive  point,  he  never- 
theless, taking  all  in  all,  feels  just  as  ill  as  he  did  before.  On  that  day 
he  will  become  desperate,  and,  more  likely  than  not,  he  will  turn  against 
his  physician  who  will  have  '  '  humored  '  '  him,  or  '  '  occupied  '  '  him  in  such 
a  way  as  to  stop  all  his  activity  by  the  multiplicity  of  his  daily  pre- 
scriptions. We  have  seen  patients  whose  whole  day  was  taken  up  by  the 
treatments  to  which  they  were  supposed  to  devote  themselves.  We  have 
met  others  who  weighed  their  food,  who  measured  their  drinks  down 
to  a  teaspoonful,  because  some  insidious  analysis  of  urine  had  shown 
an  excess  of  such  and  such  a  product  and  an  insufficient  quantity  of 
some  other,  which  was  to  be  compensated  for  either  by  increase  or 
diminution  in  the  matter  of  food.  Certainly  during  the  time  that  they 
gave  themselves  up  to  all  these  little  ceremonies  the  patients  were  dis- 
tracted, and  in  their  care  forgot  the  very  cause  which  necessitated  them. 

But  all  the  same,  in  the  end,  when  the  weary  and  discouraged  pa- 
tient has  thrown  over  his  physic  and  his  physician,  he  will  not  be  able  to 
give  up  all  at  once  the  habits  of  self- observation  which  he  will  have 
contracted,  nor  will  he  renounce  that  conviction  which  has  been  im- 
planted in  him  that  it  is  outside  of  himself  and  in  the  therapeutic 
resources  which  chemistry  and  physics  furnish  to  the  physician  that  he 
ought  to  find  his  cure.  He  will  repudiate  his  medications  and  his 
doctor,  but  it  will  only  be  to  turn  to  some  other  physician  and  to  get 
some  other  medicine. 

It  would  be  hard  to  say  how  much  time  may  be  lost  in  this  way  by 
patients.  We  have  seen  some  who  have  been  in  miserable  health  for 
five,  ten,  or  twenty  years.  There  are  some  who  have  drugged  themselves 
during  their  whole  life.  There  are  some  people  who,  without  any  ques- 
tion, have  devoured  what  would  amount  to  the  contents  of  a  whole 
pharmacy  in  some  small  country  town,  and  who  have  on  this  account  a 
worn-out  stomach  and  suffer  from  what  is  justly  entitled  medicinal  gas- 
tritis. Do  not  let  any  one  imagine  that  by  such  processes  the  physician 
gains  the  confidence  of  his  patient,  and  that,  merely  by  varying  his 
prescription  and  changing  his  medications,  whose  action  is  useless,  he 
will  be  assured  of  his  patient's  fidelity.  Nothing  is  more  false.  We 
have  known  neuropaths  who  have  consulted  ten,  twenty,  thirty 
physicians.  That  is  nothing.  We  have  seen  a  list  of  fifty-six  physicians 
consulted  by  a  false  gastropath  in  the  space  of  a  few  years,  and  a  certain 
patient  whom  we  know,  who  is  unquestionably  neurasthenic  and  not 
hypochondriacal,  changes  his  physician  every  two  months  on  an  aver- 
age.   He  has  been  sick  sixteen  years.    Imagine  his  bills. 

Therefore,  no  medication  for  neuropaths.  The  method  is  dangerous 
and  inefficacious,  and  its  greatest  inconvenience  is  the  fact  that  it  gives 
the  patient's  psychism  an  orientation  which  is  directly  opposed  to  that 
which  one  wants  to  see  him  take.  No  medicine,  we  say,  except  what 
may  be  quite  incidental,  for  it  is  perfectly  evident  that  one  would  be 


STUDY  OF  TREATMENT  OF  PSYCHONEUROSES.       277 

justified  in  giving  a  few  grains  of  quinine  to  a  neurasthenic  who  has  a 
touch  of  the  grippe.  But  the  medication  of  the  wonder-working  doctor 
who  wants  to  exercise  suggestion,  and  the  medication  of  the  organicist 
physician  who  pretends  to  reduce  a  theoretic  nervous  exhaustion  or  an 
external  irritability,  are  equally  dangerous,  and  ought  to  be  equally 
proscribed. 

As  for  physiotherapy,  which  is  bad  if  it  pretends  to  be  pathogenic 
therapy,  it  may,  on  the  contrary,  be  indicated,  and  give  good  results  if 
it  consents  to  be  nothing  more  than  the  practice  of  general  hygiene 
appropriate  to  certain  given  constitutions. 

The  only  proper  treatment  for  the  psychoneuroses,  therefore,  is 
psychic  treatment.  Although  by  no  means  all,  yet  a  very  great  number 
of  neurologists  have  come  to  agree  upon  this  point.  But  there  are  a 
great  many  differences  of^opinion  concerning  the  psychotherapeutic 
methods  to  be  employed. 

We  shall  not  dwell  upon  methods  of  indirect  suggestion.  They  are 
those  which  act  in  exactly  the  same  way  as  a  medicine  or  any  therapeutic 
proceeding  whatsoever  to  produce  upon  the  subject,  without  consulting' 
his  reason  or  his  will  and  without  any  direct  action  of  the  physician,  a 
suggestion  which  might  be  favorable.  These  are  medical  tricks.  One 
should  never  forget  that  it  is  not  enough  to  make  the  symptoms  disap- 
pear in  order  to  have  accomplished  a  real  therapeutic  result  in  the 
neuropath.  It  is  necessary  to  change  his  mental  state,  to  explain  to 
him  how  and  why  he  has  fallen  ill,  and  how  and  why  if  once  cured  he 
cannot  slip  back  again  because  he  will  have  regained  the  mastery  over 
himself.  With  miraculous  proceedings  it  is  only  the  symptom  which 
is  treated,  which,  in  our  opinion,  is  absolutely  insufficient.  From  our 
point  of  view,  there  is  only  one  series  of  cases  where  a  physician  should 
have  the  right  to  use  any  proceedings  of  this  Irind,  and  that  is  where 
certain  sexual  neuropaths  are  concerned.    We  shall  see  why  further  on. 

In  a  general  way  psychotherapeutic  methods  are  divided  into  two 
large  classes, — ^namely,  on  the  one  hand  methods  of  direct  suggestion, 
and  on  the  other  methods  of  persuasion.  The  difference  which  exists 
between  these  two  methods  is  very  important.  The  former  pretend  to 
introduce  into  the  consciousness  of  the  subject  new  ideas,  or  to  destroy 
existing  ideas,  without  his  consent  and  judgment.  The  latter  want  the 
new  ideas  to  be  introduced  with  the  consent  of  the  subject,  and  if  he 
abandons  a  conception  by  means  of  his  treatment  this  abandonment  must 
be  made  voluntarily  after  reflection  and  with  full  knowledge,  of  the 
cause. 

Direct  Suggestion. — ^Direct  suggestion  is  only  addressed  to  the 
psychological  automatism,  and  theoretically  it  would  be  all  the  more 
perfect  and  easy  if  the  subject  to  whom  it  is  addressed  would  permit  very 
few  phenomena  of  consciousness  to  intervene  during  the  course  of  the 
suggestive  act. 

The  partisans  of  direct  suggestion  are,  therefore,  logical,  within  their 


278      THE  TREATMENT  OF  PSYCHONEUROSES. 

own  lines,  when  they  demand  that  their  therapeutic  action  should  be 
exercised  during  hypnotic  sleep.  During  these  states  what  is  called 
forth,  as  well  as  what  is  acquired,  is  done  independently  of  all  conscious 
will  on  the  part  of  the  patient.  The  action  of  the  physician  is  all-power- 
ful, and  he  may  at  his  pleasure  add  to  or  withdraw  from  the  psychism 
of  the  patient  ideas  which  seem  to  him  useless  or  dangerous.  The  sug- 
gestive action  is  not  limited  to  the  suppression  of  various  somatic  symp- 
toms presented  by  the  patients,  but  may  also  be  pedagogic  in  its  nature. 
One  may  in  an  hypnotic  sleep  undertake  the  education  of  emotional 
states,  and  the  education  of  the  will,  and  analyze  and  modify  the  specific 
psychological  reaction  of  each  individual.  Such  is  at  least  the  con- 
ception of  physicians  who  are  hypnotists.  This  point  of  view  demands 
discussion. 

Hypnotism  raises,  first  of  all,  serious  questions  of  a  moral  and  social 
nature.  It  is  no  small  problem,  in  fact,  for  a  physician  to  ask  himself 
whether  he  has  the  right  to  suppress  the  free  will  of  a  subject,  and  make 
it  act  according  to  his  ideas,  even  though  he  have  a  therapeutic  end  in 
view.  But  this  is  not  the  chief  question.  It  resides  chiefly  in  the 
education  of  the  automatism  which,  to  our  way  of  thinking,  is,  if  not  the 
constant,  at  least  the  very  frequent  result  of  repeated  hypnotic  prac- 
tices. To  be  convinced  of  this  one  has  only  to  see  what  has  become  of  the 
educated  hysterics  of  former  times.  They  are  for  the  most  part  very 
helpless  people,  incapable  of  guiding  themselves  alone  through  life.  Since 
the  period  when  they  were  used  as  experimental  mediums  there  is  only 
a  very  small  number  of  them  who  have  been  able  to  go  back  to  normal 
life.  One  cannot  with  impunity  accustom  a  subject  to  accept  sug- 
gestions from  others.  It  is  a  direct  and  negative  attack  on  the  individual 
personality  which  is  thus  put  into  practice,  and,  although  the  personality 
may  be  modified  by  hypnotism,  it  is  most  assuredly  not  along  the  line  of 
its  development,  but  rather  in  the  line  of  deterioration  and  weakness.  The 
reason  that  for  a  certain  number  of  years  no  one  perceived  the  dangers 
of  hypnotism  was  because  one  could  not  see  its  remote  results.  In  our 
days,  further  removed  from  the  starting  of  the  method,  we  are  able  to 
state  that  it  presents  a  great  many  dangers  which  more  than  overbalance 
the  advantages  which  may  arise  from  it.  It  is  true  that  one  cannot 
always  make  certain  neuropathic  symptoms  disappear  as  rapidly  with 
persuasion  as  by  hypnotic  suggestion.  But  what  advantage  is  there 
in  suppressing  the  symptoms  if  the  underlying  foundation  remains,  and 
all  the  more  if  this  foundation  is  modified  in  such  a  way  that  new 
symptoms  will  have  a  better  chance  of  developing  upon  it? 

Hypnotism  also  raises  another  social  question,  for  the  automatism 
of  major  hypnosis  may  be  pushed  so  far  that  such  subjects  might  be- 
come a  real  danger  to  society,  if  they  met  anybody  in  their  life,  who 
was  ready  to  take  advantage  of  their  automatism  to  use  it  for  his  own 
ends.    One  remembers  the  discussions  in  which,  apropos  of  a  celebrated 


STUDY  OF  TREATMENT  OF  PSYCHONEUROSES.       279 

case,  the  neurologists  of  the  two  opposite  schools  of  Salpêtrière  and 
Nancy  took  part.  It  certainly  seems  that,  for  certain  subjects  at  least, 
it  was  the  school  of  Nancy  which  was  in  the  right,  and  that  a  deeply 
hypnotized  individual  might,  by  the  will  of  others,  be  urged  to  perform 
any  act,  including  crime.  For  our  part  we  are  convinced  of  this.  The 
judicial  chronicle  reminds  us  that  hypnotism  offers,  on  the  other  hand, 
certain  dangers  to  physicians.  A  great  many  women  who  have  been  put 
to  sleep  have  pretended  that  it  was  not  only  their  psychological  freedom 
which  the  physician  had  forced  them  to  yield.  Along  this  line  of  ideas 
there  are  numerous  dangers,  not  only  for  the  physician  but  also  for 
the  patient,  who,  by  reason  of  accepting  foreign  suggestions,  finally  will 
admit,  by  reason  of  secondary  conviction,  the  most  impossible  auto- 
suggestions. This  is,  moreover,  one  of  the  things  which  prove  the 
psychological  danger  of  hypnotism,  because,  if  the  physician  really  had 
simply  as  a  therapeutic  means  given  a  narcotic  to  his  patient,  he  would 
be  open  to  the  same  accusations.  But  what  he  has  done  in  practising 
hypnotism  is  to  develop  the  power  of  the  psychological  automatism  and 
to  diminish  the  value  and  intensity  of  intellectual  control,  and,  in  a  very 
great  measure,  the  physician  is  responsible  for  the  faculty  of  auto-sug- 
gestion which  his  patient  has  thus  acquired.  The  most  ridiculous  ideas 
which  in  a  perfectly  involuntary  way  cross  the  field  of  consciousness, 
in  a  subject  thus  educated,  will  tend  to  be  admitted  without  discussion 
by  him  as  real  and  demonstrable  phenomena.  After  his  mental  mechan- 
ism has  acquired,  under  the  influence  of  repeated  hetero-suggestions,  the 
habit  of  admitting  without  criticism,  the  ideas  that  a  foreign  will  has 
tried  to  introduce  into  it,  it  would  seem  plausible  after  this  that  the 
ideas  which  spring  from  the  psychological  automatism  across  the  field 
of  consciousness  should  tend  to  come  back  into  this  automatism  in  the 
form  of  facts  of  memory  admitted  just  as  if  they  had  been  examined  and 
exactly  as  may  have  been  in  the  case  of  hypnotic  suggestion.  Although 
they  say  that  the  hypnotic  memory  in  its  definition  is  only  addressed 
to  the  psychological  automatism,  yet  it  tends  to  develop  it  at  the  ex- 
pense of  the  functions  of  consciousness  and  judgment.  Hypnotism  is 
only  a  logical  method  for  those  who  believe  in  a  very  narrow  determinism 
of  the  psychic  functions,  and  who,  denying  the  existence  of  superior 
psychic  phenomena,  consider  the  human  mechanism  as  a  tool  which  one 
can  regulate  or  put  out  of  order  at  will.  We  do  not  belong  to  this  class. 
Hypnotism,  it  seems  to  us,  may  do  for  the  psychoneuroses  what  certain 
symptomatic  therapeutics  may  do,  for  example,  for  an  infectious  dis- 
ease. What  would  one  think  of  a  physician  who,  in  order  to  diminish 
some  symptom, — such  as  fever,  for  example, — ^would  order  such  medi- 
cine as  would,  at  the  same  time  that  it  was  lowering  the  temperature, 
diminish  the  resistaace  of  the  patient  to  the  infection  ? 

But  that  is  not  all.     First  of  all,  the  hypnotic  method  should  be 
employed  differently  for  each  kind  of  patient.     There  are  very  many 


280      THE  TREATMENT  OF  PSYCHONEUROSES. 

subjects  who  are  not  hypnotizable.  There  are  others,  who  are  still  more 
numerous,  to  whom  the  idea  of  entrusting  their  free  will  into  the  hands 
of  a  physician,  even  of  one  in  whom  they  would  have  the  greatest  con- 
fidence, is  peculiarly  depressing.  One  does  not  give  up  his  will  and 
his  personality  so  easily,  and  we  have  known  subjects  in  whom  the  very 
emotion  which  had  been  caused  by  certain  attempts  at  hypnosis  had 
brought  about  new  and  very  serious  neuropathic  manifestations. 

On  the  other  hand,  we  must  understand  the  exact  value  of  hypnotic 
suggestion.  Here  is  an  individual  to  whom  in  hypnotic  sleep  you 
make  some  suggestion  for  a  future  time.  You  order  him,  for  example, 
to  write  a  letter  or  to  make  a  visit  several  weeks,  or  perhaps  seve^ral 
months,  later.  The  suggested  date  arrives,  and  our  subject  achieves  the 
suggestion  satisfactorily;  but  he  achieves  it  in  a  secondary  condition, 
— ^that  is  to  say,  in  a  purely  automatic  state.  Once  the  act  is  accom- 
plished he  retains  no  memory  of  it.  At  no  moment  has  he  had,  either 
at  the  time  of  the  suggestion  or  during  the  execution  of  the  suggested 
act,  any  phenomenon  of  consciousness.  The  suggestion,  in  other  words, 
was  only  able  to  act  when  the  faculties  of  consciousness  were  lost.  At 
these  two  periods,  during  the  order  and  the  execution,  the  suppression 
of  consciousness  is  the  essential  condition  of  suggestion.  In  what  measure 
has  the  hypnotic  suggestion,  therefore,  any  persistent  action  upon  the 
individual  when  he  has  regained  his  state  of  consciousness?  This  is  a 
question  that  one  has  the  right  to  ask,  and  of  which  the  negative  solution 
shows  how  illusory  is  the  pedagogic  action  of  hypnotic  suggestion.  On 
the  other  hand,  as  a  matter  of  fact,  the  real  action  of  hypnosis  has 
always  appeared  to  us  to  be  limited  to  neuropathic  symptoms  depending 
more  or  less  directly  upon  psychic  automatism.  Hysterical  manifesta- 
tions, in  so  far  as  they  are  accidental,  may  sometimes  disappear  rapidly 
under  the  influence  of  hypnotic  suggestion.  We  have  seen,  on  the  con- 
trary, many  neurasthenics  who  have  never  found  that  such  therapy 
has  been  of  any  benefit  whatsoever  for  the  functional  symptoms  pre- 
sented by  them.  This  is  because  in  such  cases  it  is  a  question  of  troubles 
engendered  by  preoccupation,  and  in  which  the  intervention  of  the 
psychological  automatism  is  only  secondary. 

Along  this  same  line  of  ideas  bearing  on  pedagogic  influence, — or, 
if  one  so  prefers  it,  of  the  possible  modification  of  the  soil, — a  very  im- 
portant thing  in  matters  of  psychotherapy — which  hypnotic  suggestion 
may  bring  to  pass,  one  must  always  take  into  consideration  the  patient's 
usual  habit  of  thought.  It  is  very  evident  that  the  value  of  a  psychic 
acquisition  is  measured  by  the  number  and  importance  of  the  ideas  with 
which  it  is  associated.  For  a  religious  subject  it  is  certain  that  any  idea 
which  has  to  do  with  his  convictions  will  have  an  enormous  value  in 
directing  his  thoughts.  To  a  cowardly  subject  any  idea  bearing  on  the 
subject  of  sickness  or  death  will  have  considerable  weight.  On  the  other 
hand,  by  the  action  of  repetition,  any  idea  which  is  associated  with  a 


STUDY  OF  TREATMENT  OF  PSYCHONEUROSES.       281 

great  number  of  facts  in  life  will  gradually  assume  a  greater  and  greater 
importance  in  the  psychism  of  the  subject.  But  the  value  of  hypnotic 
suggestion  is  to  express  itself,  as  it  were,  on  a  blank  page,  to  associate 
itself  with  nothing  and  to  be  dependent  on  nothing.  But  what  effect 
can  it  have,  under  these  conditions,  on  the  psychical  or  moral  orientation 
of  a  patient  ? 

On  the  other  hand,  it  has  seemed  to  us,  in  some  cases,  that  hypnotic 
suggestion  may  overshoot  the  mark,  and  tend  continually  to  put  the 
subjects  into  subconscious  states  approaching  those  secondary  conditions 
where  suggestive  action  then  becomes  preponderant. 

However  it  may  be,  hypnosis  is  none  the  less  extremely  interesting 
from  the  point  of  view  of  psychological  analysis.  Were  it  only  that  it 
has  permitted  the  dissociation  of  the  automatic  functions  and  the 
functions  of  consciousness,  it  should,  for  this  reason  alone,  receive  the 
thanks  of  physicians.  For,  by  this  very  act,  it  permits  one  to  see  that 
all  psychotherapy  should  first  and  foremost  be  addressed  to  the  functions 
of  consciousness,  and  that  a  method  such  as  hypnotic  suggestion  which 
is  addressed  to  the  functions  of  the  automatonism  can  no  longer  be 
practised  at  the  present  time.  In  other  words,  the  results  of  the  psycho- 
logical analyses  which  are  made  possible  by  means  of  hypnotic  sleep  con- 
demn its  use  as  a  therapeutic  method. 

A  very  different  thing  from  hypnotic  suggestion  is  suggestion  during 
the  waking  state.  This  is  practised  under  peculiar  conditions.  In  a 
semi-obscure  room  removed  from  the  noise  of  the  street,  the  doctor  settles 
his  patient  comfortably.  It  is  necessary  that  there  should  be  no  physical 
discomfort  and  that  his  attention  should  not  be  attracted  by  any  outside 
phenomenon.  Then  the  physician  tells  him  to  close  his  eyes  and  to  put 
himself  into  such  a  condition  that  no  thought  or  sensation  may  come 
in  between  the  psychism  of  the  subject  and  the  suggestion  which  the 
physician  is  going  to  make.  It  is  understood  that  the  patient,  when 
thus  placed  in  this  condition  of  receptivity,  which  under  these  circum- 
stances is  voluntary,  is  not  supposed  to  discuss  an3i;hing.  He  must, 
without  reasoning,  and  without  any  psychic  reaction  whatever,  accept 
the  suggestion.  This  will  chiefly  be  put  in  the  form  of  repeated  affirma- 
tions. It  could  not,  naturally,  _be  in  any  degree  an  argument  or  a 
demonstration,  of  which  the  first  result  would  be  to  awaken  the  psychism 
of  the  patient.  One  could,  if  absolutely  necessary,  multiply  his  state- 
ments by  dividing  them  into  short  sentences.  One  might  subdivide  the 
symptom  picture  presented  by  the  patient  into  a  series  of  elementary 
symptoms,  and  oppose  a  suggestive  statement  against  each  one  of  these. 
Surrounded  with  a  little  sense  of  mystery,  and  by  the  very  force  of 
things  complicated  by  phenomena  of  auto-suggestion,  and  having  its 
results  perhaps  only  through  the  intermediary  of  this  auto-suggestion, 
there  is  no  doubt  that  this  practice  may  lead  to  a  great  number  of  good 
results  in  the  therapy  of  neuropathic  symptoms. 


282      THE  TREATMENT  OF  PSYCHONEUROSES. 

It  is  very  evident  that  this  method  has  none  of  the  preliminary  in- 
conveniences of  hypnotic  suggestion.  It  does  not  make  a  disagreeable 
impression  upon  the  patient,  who  has  no  fear,  as  in  hypnosis,  of  feeling 
himself  both  psychically  and  physically  abandoned  to  the  mercy  of  his 
physician.  The  latter,  moreover,  always  takes  pains  to  reassure  his  pa- 
tient on  this  point,  and  promises  to  awaken  him  if  he  should  happen  to 
fall  into  an  hypnotic  sleep. 

As  a  matter  of  fact,  it  often  does  happen  that  during  this  practice 
the  patient  goes  to  sleep  and  falls  into  an  hypnotic  condition.  Also, 
there  are  a  great  many  physicians  to  be  found  who  do  not  see  that  sug- 
gestion in  the  waking  state  differs  from  hypnotic  suggestion  in  any  way 
except  in  degree,  and  who  consider  the  peculiar  condition  in  Avhich  the 
patient  must  be  placed  to  submit  to  suggestions  as  merely  a  less  marked 
state  of  hypnosis. 

However  this  may  be,  although  we  regard  this  method  as  in  all  re- 
spects less  dangerous  than  hypnotic  suggestion,  yet  we  wish  to  point  out 
a  great  many  objections  which  it  seems  to  raise.  Evidently  the  most 
important  objection  is  that  in  this  treatment  one  deliberately  directs 
one's  attention  to  the  symptom,  and  completely  neglects  the  underlying 
mental  stratum.  By  direct  suggestion  one  weakens  instead  of  strength- 
ening the  patient's  critical  power.  It  does  not  in  any  way  accustom 
him  to  judge  his  impressions  and  to  recognize  the  value  of  his  sensa- 
tions. Here  again  the  attempt  to  help  improve  the  symptoms  or  to  cure 
by  outside  suggestion  only  tends  to  reinforce  the  patient's  auto-  and 
hetero-suggestibility,  which  form  the  very  source  of  his  symptoms. 

In  an  intermediary  position  between  indirect  suggestion  and  per- 
suasion there  are  some  rather  specialized  therapeutic  processes  which 
tend  to  arouse,  either  by  direct  or  mediatory  action,  curative  auto- 
suggestions in  patients.  In  this  way,  by  starting  from  the  suggestive 
power  of  a  saying,  either  written,  read,  or  repeated  mentally  or  aloud, 
one  can  make  the  patient  who  is  afflicted  with  neurasthenic  headache 
or  hysterical  paralysis  either  write,  or  read,  or  say,  *'I  have  no  head- 
ache; I  can  walk."  Such  a  method  may  be  varied  infinitely,  and  de- 
pends chiefly  on  the  fact  that  the  word,  or  the  gesture,  constitutes  by 
its  relation  to  the  psychism  of  the  patient  the  reality  of  the  idea  or 
action. 

Here,  as  the  intrinsic  suggestion  is  worthless,  it  is  likely  that  the  un- 
favorable effect  produced  on  the  mental  make-up  is  not  so  great.  It  must 
be  added,  that  from  the  therapeutic  point  of  view  the  results  are  not 
very  brilliant,  and  that,  in  spite  of  all,  a  method  which  accustoms  one 
to  interpose  psychic  operation  cannot  but  be  inconvenient  to  the  mental 
constitution  of  the  subject  in  question.  We  have  seen  patients  of  this 
kind  who  could  not  bring  themselves  to  decide  upon  any  action  whatso- 
ever without  repeating  to  themselves  a  great  many  times:  **I  will  do 
such  and  such  a  thing."    The  word,  for  them,  had  become  the  means  of 


STUDY  OF  TREATMENT  OF  PSYCHONEUROSES.       283 

action,  and  the  necessarj^  intermediary  between  the  action  and  its  con- 
ception. This  is  the  ultimate  outcome  of  such  therapeutic  practices  as 
we  have  just  described. 

We  have  now  briefly  analyzed  ^  the  different  psychotherapeutic  proc- 
esses which  taken  as  a  whole — although  varying  in  the  degree  in  which 
they  suppress  consciousness — are  addressed  to  the  cerebral  automatism 
and  practically  lead  to  relapse. 

Persuasion. — ^We  come  now  to  psychotherapy  by  persuasion.  Here 
there  is  no  more  stage  setting,  no  more  drawn  curtains,  no  more  closed 
shutters — ^nothing  which  would  be  calculated  to  impress  the  patient. 
The  conversational  attitude,  the  familiar  manner  of  talking  things  over, 
the  heart-to-heart  discussion,  where  the  physician  must  exert  his  good 
sense  and  feelings,  and  the  patient  be  willing  to  be  confidential, — ^this 
is  what  is  meant  by  psychotherapy  by  persuasion.  It  consists  in  ex- 
plaining to  the  patient  the  true  reasons  for  his  condition,  and  the  differ- 
ent functional  manifestations  which  he  presents.  It  consists,  on  the 
other  hand,  moreover,  and  you  would  say  almost  wholly,  in  establishing 
the  patient's  confidence  in  himself  and  awakening  the  different  elements 
of  his  personality  capable  of  becoming  the  starting-point  of  the  effort 
which  will  enable  him  to  regain  his  self-control.  The  exact  compre- 
hension of  phenomena  which  he  presents  must  be  grasped  by  the  patient 
by  means  of  its  own  reasoning.  The  general  elements  which  may  in 
some  way  build  up  his  mental  synthesis  must  be  drawn  upon  by  his 
own  volition.  The  part  that  the  physician  plays  is  to  recall,  awaken, 
and  direct.  He  has  nothing  to  do  with  suggestions.  All  conceptions 
and  ideas  which  the  physician  puts  forth  should  be  such  as  would  appeal 
to  the  patient's  reason,  and  should  not  come  into  collision  with  either 
his  convictions  or  his  feelings.  When  the  physician  shows  a  patient  in 
what  way  he  has  erred,  what  are  the  faults  of  his  character  and  his 
moral  condition  and  his  reasoning  which  are  the  cause  of  the  genesis 
of  his  affection,  he  does  not  demand  that  he  shall  accept  what  he  has 
told  him  as  an  article  of  faith:  he  asks  only  one  thing, — ^that  he  should 
force  himself  to  reflect  and  to  understand. 

Far  from  acting,  as  do  direct  suggestions,  by  restricting  the  per- 
>  sonality,  persuasion,  on  the  contrary,  tends  to  permit  the  personality  to 
develop,  in  liberating  it  from  all  the  disordered  actions  which  may  have 
been  established  by  bad  moral  hygiene  or  by  vicious  physical  or  psychic 
attitudes.  And  if,  as  is  the  rule,  the  subject  is  cured,  it  ought  to  seem 
to  him  that  he  has  evaded  his  neuropathic  condition  through  his  own 
efforts,  and  that  it  is  he  himself  who  has  successively  cut  or  disentangled 
the  bonds  which  had  kept  him  there.  One  can  see  how,  in  this  way,  the 
self-confidence  of  the  patient  who  is  cured  is  augmented.    His  feeling 

^  For  a  more  complete  and  definite  exposition  of  different  psychothérapie  proc- 
esses we  refer  the  reader  to  the  work,  "  Isolement  et  Psychothérapie,"  by  J.  Camus 
and  P.  Pagniez,  published  under  the  direction  of  one  of  us  (Paris,  1904,  Alcan) . 


284      THE  TREATMENT  OF  PSYCHONEUROSES. 

of  safety  is  complete  if  he  has  been  wisely  treated, — quite  complete 
enough  in  all  cases  for  the  patient,  conscious  of  the  faults  which  he  has 
committed,  and  recognizing  the  dangers  which  threaten  him,  to  know 
that  he  can  and  must  guard  himself  against  one  and  the  other.  The 
risk  of  relapse  to  the  neurasthenic  cured  by  persuasion  is  almost  noth- 
ing. He  may  have  times  of  weakness,  but  he  will  remember  and  pull 
himself  up  and  get  hold  of  himself  again. 

It  goes  without  saying  that  persuasion  can  only  be  applied  to  in- 
dividuals whose  mental  mechanism  is  virtually  sane.  If  it  is  brought  to 
bear  upon  subjects  whose  psychic  functions  are  either  congenitally  or 
accidentally  and  organically  affected,  it  is  certain  to  meet  with  defeat. 
There  is  no  psychotherapy,  such  as  we  understand  it,  for  people  with 
major  obsessions,  for  melancholias  or  circular  psychoses,  any  more  than 
there  is  psychotherapy  for  the  psychoses.  We  feel  that  it  only  casts  dis- 
credit upon  the  method  to  think  of  applying  it  to  this  class  of  patients. 
One  cannot  give  a  new  orientation  to  a  mentality  which  is,  as  it  were, 
crystallized  in  a  definite  situation.  And  although  some  authors  may 
have  had  improvements  or  cures  among  patients  afflicted  by  some  kind 
of  mental  affection,  it  has  been  owing  to  a  happy  chance  for  their  sub- 
jects, but  an  unfortunate  one  for  them,  for  it  has  been  the  starting- 
point  of  their  errors.  They  have  found  themselves  confronted  by  periods 
of  natural  and  spontaneous  remission  which  occur  in  the  great  majority 
of  subjects  afflicted  with  these  mental  affections. 

On  the  other  hand,  and  even  where  the  psychoneuroses  are  concerned, 
there  are  peculiar  cases  which  we  shall  have  to  consider  in  the  course  of 
this  study,  where  persuasion  loses  its  power.  Often  it  is  a  question  of 
an  almost  pathological  mentality  in  certain  subjects.  On  the  other  hand 
also,  it  is  because,  before  having  had  recourse  to  psychotherapy,  per- 
emptory indications — drawn,  for  example,  from  the  subject's  general 
condition — ^have  obliged  one  to  act  first  and  talk  afterward,  and  some- 
times too  late. 

If,  however,  psychotherapy  is  the  chosen  method  to  be  applied  to 
the  great  majority  of  patients,  it  must  also  be  recognized  that  there  are 
cases,  and  very  many  of  them,  where  it  can  only  be  practised  under 
certain  given  conditions,  which  are  necessary  and  preliminary  to  the 
treatment.  The  most  frequent  of  these  conditions  is  isolation,  and  there 
are  nervous  people  for  whom,  without  isolation,  all  psychotherapeutic 
methods  would  be  in  vain. 

There  are,  therefore,  in  the  treatment  of  the  psychoneuroses  certain 
psychotherapeutic  accessories  which  we  shall  have  to  study.  Essen- 
tially a  psychoneurosis  is  composed,  as  we  have  seen — 

1.  Of  a  mental. and  moral  foundation  which  is  either  constitutional 
or  acquired,  and  due  to  some  emotional  stimulus. 

2.  Neuropathic  symptoms  properly  so  called,  or  functional  mani- 


STUDY  OF  TREATMENT  OF  PSYCHONEUROSES.       285 

festations,  grafted  on  to  the  psychic  stock  which  has  hitherto  been 
established. 

3.  Additional  phenomena,  expressing  the  persistence  of  functional 
manifestations  in  the  organs. 

For  convenience  in  description,  and  after  having  devoted  several 
pages  to  the  medical  examination  of  neuropaths,  we  shall  take  up  suc- 
cessively the  treatment  of  each  one  of  these  constituent  elements  of  the 
psychoneuroses.  Naturally,  this  must  be  a  schematic  and  purely  artificial 
division,  for  in  the  treatment,  just  as  in  the  disease,  symptoms  are  evi- 
dently bound  up  together.  Finally  the  actions  exercised  upon  the  dif- 
ferent troubles  presented  by  the  patients  depend  one  upon  the  other. 

Having  prepared  the  way,  we  shall  then  take  up  the  accessories  of 
psychotherapy.  In  a  final  chapter  w^e  shall  try  to  see  how  and  to  what 
degree  the  psychoneuroses  are  susceptible  of  preventive  treatment,  and 
how  the  physician  who,  in  a  prophylactic  manner,  has  been  until  the 
present  bound  up  in  his  ideas  of  physical  hygiene  may  also  assume  the 
right  to  interest  himself  in  this  question  of  mental  hygiene,  which, 
moreover,  is  so  often  an  accompanying  element  of  physical  hygiene,  as 
it  is  also  a  requisite  to  a  very  great  degree  of  the  general  health  of 
society. 


^v. 


CHAPTER  XX. 

THE  EXAMINATION  AND  QUESTIONING  OF  THE  NEUROPATH. 

Upon  the  first  encounter  between  the  physician  and  the  neuropath 
depends  the  fate  of  the  combat.  If  from  the  first  conversations  you  have 
not  been  able  to  awaken  a  reciprocal  sympathy  in  your  patient,  and  if  you 
have  not  succeeded  in  gaining  his  confidence,  it  is  useless  to  go  any 
further.     The  result  that  you  will  obtain  will  be  worthless  or  mediocre. 

But  it  would  be  wrong  to  imagine  that  it  is  extremely  difficult  to 
gain  the  confidence  of  a  neuropath.  The  nervous  person  is  usually 
extremely  susceptible.  He  is  not  at  all  willing  to  show  confidence  in 
any  one  who  has  not  gained  it,  but  he  is  also  extremely  sensitive  to 
kindly  treatment,  and  quite  ready  to  confide  in  any  one  whom  he  sees 
interested  in  his  fate.  Also,  if  the  neuropath  in  his  explanations  is  often 
somewhat  prolix,  and  if  he  bring  into  his  descriptions  things  which  seem 
to  you  wholly  unimportant,  do  not  become  impatient  with  him.  It  will 
sometimes  happen  that  a  detail  which  seems  insignificant  at  first  may, 
as  matters  develop,  be  extremely  useful  to  you.  It  will  also  happen 
that  when  carried  away  by  his  own  subject  the  patient  will  reveal  him- 
self much  more  completely,  if  you  let  him  go  on,  than  if,  with  the  air 
of  hurrying  him  on  to  be  rid  of  him,  you  try  to  get  him  to  be  concise 
when  it  is  impossible  for  him  to  be  so.  Not  only  must  you  let  him  speak, 
but  you  must  listen  to  him.  You  must  make  notes,  in  your  memory  at 
least, — and,  if  that  is  not  trustworthy,  in  writing, — of  all  the  ideas 
which  the  patient  may  have  concerning  the  nature  and  the  causes  of 
his  condition.  These  notes  you  will  use  later  on.  They  will  often  serve 
to  convince  the  patient  of  his  own  contradictions,  and  it  is  hard  to 
realize  how  often  it  is  necessary  to  use  the  argument  which  begins  with 
*'But  you  told  me  several  days  ago  that " 

Before  entering  into  any  discussion  with  your  patient,  you,  as  the 
physician,  must  yourself  have  acquired  as  complete  an  idea  as  possible 
concerning  his  condition  and  the  mechanism  of  his  symptoms.  It  is 
not  the  time  beforehand  to  launch  out  upon  any  systematizations  based 
upon  your  own  reasoning:  you  will  run  too  much  risk  of  making  a 
mistake,  and  of  undermining  the  confidence  but  not  the  convictions  of  the 
patient. 

Then,  when  you  make  an  appointment  with  your  patient,  try  to  have 
at  least  an  hour  free  before  you.  This  is  seldom  too  much.  Often  it  is 
not  enough.  If  in  this  hour  you  have  not  finished  your  examination, 
ask  your  patient  to  come  back  the  next  day.  If  possible  makei  your 
examination  in  three  or  four  visits,  but  do  not  begin  any  therapeutic 
measures  before  having  finished  it.  In  the  first  conversation  plan  it,  if 
286 


EXAMINATION  AND  QUESTIONING  OF  NEUROPATHS.    287 

possible,  to  understand  thoroughly  the  character  of  your  patient.  This 
is  really  very  important,  because  in  neuropaths,  however  they  may  be 
affected,  you  will  nearly  always  detect  by  careful  questioning  some 
former  tendency,  which  may  be  more  or  less  marked,  to  emotionalism; 
this  is  what  makes  it  possible  to  say  that  with  these  patients  nothing  new 
has  been  created,  and  that  all  the  symptoms  of  which  they  complain  are 
only  an  exaggeration,  sometimes  extreme  and  sometimes  an  unhealthy 
exaggeration,  of  their  former  character. 

Finally,  and  chiefly  at  the  beginning  of  the  treatment,  the  psycho- 
therapeutist  must  very  carefully  weigh  his  words^  The  neuropath,  in 
fact,  is  usually  endowed  with  an  excellent  memory  for  everything  that 
pertains  to  his  condition  and  his  health,  and,  paying  great  attention  to 
the  words  of  his  physician,  he  will  seize  upon  the  slightest  apparent  or 
real  contradiction  to  anything  pertaining  to  what  has  been  said  before. 
By  this  fact  his  confidence  in  his  physician  would  be  injured,  and  the 
results  of  the  treatment,  if  not  compromised,  would  at  least  be  delayed. 

As  a  rule,  the  patient  who  reaches  the  neurologist  has  already  been 
seen  by  a  certain  number  of  physicians,  who  will  have  always,  or  at  least 
nearly  always,  expressed  the  results  of  their  examinations  in  terms 
which  are  purely  physical.  Thus,  your  patient,  at  first,  is  going  to  tell 
you  about  all  the  troubles  which  he  supposes  has  injured  the  general 
functioning  of  his  organism,  and  to  which  he  refers  his  whole  present 
condition.  He  wiU  tell  you  of  his  asthenia,  of  his  pains,  of  his  head- 
aches, and  of  his  gastric  and  intestinal  troubles.  When  he  has  exhausted 
the  series  of  clinical  manifestations,  take  your  turn,  and  try  to  find  out 
if  he  has  had  any  trouble  with  organs  w^hich  he  has  not  mentioned  in  his 
dissertation.     You  will  then,  in  this  way,  avoid  having  him  say,  the 

next  time  he  comes  to  see  you,  *'0h,  doctor,  I  forgot  that "    In  other 

words,  in  speaking  he  will  attribute  this  f orgetfulness  to  himself,  but,  as 
a  matter  of  fact,  in  his  inner  thoughts  he  will  think  that  you  have  ex- 
amined him  very  carelessly.  Do  not,  therefore,  forget,  in  this  first 
phase  of  your  questioning,  any  organ  or  any  function.  Whether  it 
happens  to  be  a  man  or  a  woman,  be  sure  not  to  forget  to  ask  a  certain 
number  of  questions  concerning  the  condition  of  the  sexual  functions. 
These  disturbances  the  patients  will  be  very  anxious  to  hide,  and,  if  they 
manage  to^  conceal  them  from  you,  they  will  consider  that  they  have 
scored  the  first  victory  over  you.  They  will  then  have  the  upper  hand, 
and  you  will  have  difficulty  in  obtaining  it  again. 

After  having  reached  the  end  of  this  examination  of  what  one  might 
call  physical  consciousness,  sum  up  everything  that  seems  to  you  to  have 
come  from  it  in  the  form  of  facts  which  you  have  appeared  to  acquire. 
'*In  fact,''  you  will  say  to  your  patient,  **you  complain  of  suffering 
from  insomnia,  characterized  by  .  .  .  ;  coming  on  regularly  (or  inter- 
mittently) .  .  .  ,  accompanied  by  .  .  .  ;  you  have  gastric  disturbances, 
appearing  at  such  a  time  of  day,  under  such  and  such  conditions,  and 


288      THE  TREATMENT  OF  PSYCHONEUROSES. 

influenced  (or  not)  by  your  food  .  .  .  etc."  From  this  time  on,  your 
subject  must  have  the  very  distinct  impression  that  you  are  completely 
en  rapport  with  his  physical  condition.  It  is  necessary,  however,  that 
from  all  this  you  should  have  made  private  notes  of  the  various  illogical 
points  in  the  symptomatology  described.  Finally,  this  part  of  your 
questioning  will  only  come  to  an  end  when,  before  your  little  exposition, 
which  perhaps  may  have  to  be  done  over  several  times,  your  patient  will 
say  to  you,  ''Yes,  that  is  exactly  how  it  is." 

He  will  immediately  propose  that  you  should  examine  him,  but  the 
moment  for  this  examination  has  not  yet  come.  The  major  part  of 
your  work  remains  to  be  accomplished.  This  means  that,  from  this 
moment  on,  you  must  establish  for  yourself  the  chain  of  development. 
It  is  necessary  to  know,  first  of  all,  how  all  these  related  disturbances 
have  followed  one  another;  it  is  of  the  utmost  importance  to  find  out 
their  relations  to  emotional  causes,  and  to  the  phenomena  of  auto-  and 
hetero-suggestion  which  may  have  caused  them,  and  the  affective  and 
transient  symptoms  of  physical  life  which  may,  by  the  mechanism  of  the 
psychic  crystallization  of  memory,  have  given  rise  to  actual  symptoms. 

If  a  woman,  for  example,  presents  gastric  disturbances,  do  not  for- 
get that  her  troubles  may  have  really  been  justified  in  the  beginning  by 
pregnancy.  In  a  man,  it  may  have  been  a  passing  attack  of  alcoholism, 
dating  back  some  years,  which  has  brought  back  to  him  the  manifesta- 
tions which  he  now  presents.  In  another  case,  it  may  be  a  transient 
action  due  to  medicines,  in  still  another  to  some  alimentary  intoxication, 
while  in  another  it  may  have  been  a  conversation  or  something  that 
the  patient  read.  In  this  case  it  may  be  contact  with  patients  who  were 
really  suffering  from  some  functional  disorder,  while  in  that  one  it  may 
be  the  memory  of  some  heredity  which  is  the  cause  of  it.  It  is  very 
hard  to  imagine  the  great  variety  of  causes  which  in  some  form  of 
functional  manifestation  or  other  may  give  rise  to  very  analogous 
effects. 

This  analysis,  this  searching  for  the  psychic  origin  of  the  symptom 
or  symptoms,  must  be  pushed  until  one  obtains  some  result.  It  is  the 
absolutely  essential  condition  of  treatment.  It  may  happen  that  you 
will  not  find  it  the  first  time.  It  sometimes  requires  three  or  four  con- 
ferences, before  one  can  obtain  a  sufficiently  precise  idea.  Do  not  be 
disturbed  by  this.  Your  patient  will  bear  you  no  ill  will,  for,  already 
finding  that  you  are  interested  in  considering  every  detail  so  thoroughly, 
he  will  have  complete  confidence  in  you. 

You  will  then  have  to  establish  the  condition  influencing  the  vari- 
ability— an  almost  constant  factor — in  the  symptoms  of  your  neuro- 
path. The  immediate  or  more  slowly  perceived  beneficial  or  harmful 
influence  of  distraction,  of  emotions,  and  of  preoccupations  foreign  to 
the  symptom  in  hand, — all  this  must  be  brought  out  by  your  questioning. 
Note  that  from  this  time  on,  and  without  meaning  to,  you  are  practising 


EXAMINATION  AND  QUESTIONING  OF  NEUROPATHS.    289 

therapeutic  measures.  When  your  patient  leaves  you,  he  will  be  always 
thinking  about  the  questions  which  you  have  put  to  him  ;  he  will  already 
have  experienced  a  mental  orientation  which  cannot  but  be  favorable  to 
him.  It  often  happens  that  after  simple  questioning  we  have  seen 
patients  come  back  the  next  day  and  tell  us,  '  '  Doctor,  I  have  been  think- 
ing of  all  the  questions  that  you  asked  me  yesterday,  and  I  have  been 
asking  myself  whether  or  not  it  may  be  that  I  am  simply  nervous,  and  a 
little  irritable." 

Have  you  now  finished  with  your  questionings  ?  Certainly  not.  You 
are  still  far  from  knowing  all.  You  must  now  try  to  find  out  the  general 
cause  of  the  patient's  condition.  Often,  at  the  start,  he  will  not  have 
told  you  it.  But  led  on  by  his  confidence,  because  he  is  convinced  that 
you  are  interested  in  him,  and  that  you  have  shown  a  willingness  to 
devote  your  time  to  him  which  other  physicians  have  never  had  the 
courage  to  do,  he  will  reveal  himself  to  you  more  readily.  And  when 
you  ask  him,  ''Now  let  us  see,  before  all  these  symptoms  appeared,  did 
you  not  have  any  special  sorrow,  or  annoyance^  or  emotion,  or  some 
serious  preoccupations?"  more  often  he  will  reply  in  the  affirmative  and 
will  tell  you  what  it  was.  It  may  happen  that  the  emotional  cause  was 
of  too  intimate  a  nature,  and  that  sometimes  it  involves  responsibilities 
of  others,  as  well  as  those  of  the  patient  himself.  But  it  will  only  be  a 
little  time  before  you  will  know  it,  and  that  will  be  when  you  really 
become  his  true  friend.  But  at  the  start  you  will  have  been  able  to 
know  that  it  exists,  even  if  the  patient  has  chosen  to  hide  it  ;  for  if,  as  a 
matter  of  fact,  you  watch  him  closely  at  the  time  when  you  put  such  or 
such  a  question,  you  will  see  him  hesitate  a  little,  or  grow  pale,  or  flush 
slightly,  and  show  some  signs  of  physical  emotion  at  the  memory  which 
you  have  just  called  up.  Sometimes  you  will  see  your  patient  slightly 
agitated,  his  words  will  be  abrupt,  his  face  will  contract  slightly  as  if  he 
wished  to  keep  back  tears  which  were  only  too  ready  to  flow.  Some- 
times all  that  is  necessary  at  that  moment  is  a  kindly  word  of  sympathy 
which  proves  to  him  that  you  are  quite  ready  to  give  him  a  little  affection 
and  a  little  of  yourself.  He  will  then  let  himself  go,  and  will  tell  you 
just  what  the  trouble  is.    Your  patient  is  then  three-quarters  cured. 

You  must  then  learn  the  whole  history  of  your  patient's  life, — all 
the  pleasures  that  he  has  been  able  to  get  out  of  it,  and  all  the  rancor 
which  may  have  accumulated  in  it.  You  must  know  the  smallest  detail 
of  his  family  life  and  his  conjugal  life.  Through  his  tastes,  his  actions 
and  his  reactions,  you  must  manage  to  form  a  complete  and  coherent 
picture  of  his  mental  and  moral  condition.  You  must  find  out  whether 
he  is  inclined  to  be  sentimental  or  emotional,  or,  on  the  other  hand, 
is  cold  and  indifferent.  Has  he  or  has  he  had  a  strong  feeling  of  self- 
esteem  or  of  pride?  Is  he  restless,  uneasy,  or  scrupulous?  Has  he 
religious  or  philosophic  convictions?  If  so,  what  are  they?  It  is  of 
the  utmost  importance  to  know  everything  in  order  to  understand 
19 


290      THE  TREATMENT  OF  PSYCHONEUROSES. 

everything.  If  you  know  every  trick  of  a  patient's  mind,  you  already, 
if  you  will  pardon  the  expression,  "have  got  him." 

For  this  last  examination  there  is  no  need  of  any  profound  psy- 
chology. The  psychology  of  every-day  life,  such  as  that  which  a  good 
artisan  or  honest  farmer  would  use,  is  quite  enough.  But  it  is  very 
evident  that  the  terms  which  you  would  employ  in  your  questioning 
would  vary  according  to  the  mentality,  and  the  education  which  the 
subject  has  received.  But  whether  it  is  the  case  of  a  prince  of  science, 
or  a  leader  of  finance,  or  the  heir  to  a  throne,  or  the  most  modest  of  his 
subjects,  those  feelings  which  alone  are  able  to  stir  men  are  extremely 
simple  and  quite  alike.  It  is  the  business  of  scientific  psychology  to 
separate  them  into  their  psychological  ions;  the  practising  physician 
need  not  trouble  himself  about  them.  He  has  only  need  to  know  the 
simple  bodies  which,  changing  their  names  according  to  various  lan- 
guages and  latitudes,  are,  nevertheless,  always  identical. 

It  would  be  a  great  error  to  imagine  that,  in  order  to  be  able  to  obtain 
a  complete  confession  from  a  patient,  it  is  absolutely  indispensable  to 
be  mature  in  years  or  have  great  authority.  Naturally,  by  virtue  of 
his  respectability,  or  his  age,  or  his  fame,  the  physician  may  make  more 
or  less  impression  on  his  patient  ;  but  the  youngest  physician,  practising 
in  any  little  place  in  the  country,  may  arrive,  perhaps  in  a  little  longer 
time,  at  exactly  the  same  result,  with  the  condition,  however,  which  in  this 
case  is  absolutely  indispensable,  that,  loving  his  profession,  and  looking 
upon  it  as  something  more  than  a  trade,  he  knows  how  to  make  himself 
beloved. 

However  it  may  be,  now  that  your  questionings  have  been  achieved, 
there  still  remains  for  you  to  make  a  physical  examination  of  your 
patient.  This  examination  ought  to  be  absolutely  thorough.  Your  sub- 
ject should  be  entirely  undressed,  and  preferably  lying  down.  All  the 
organs  and  all  the  functions  should  be  scrutinized  by  every  method  of 
examination  at  your  disposal.  An  analysis  of  the  urine  should  be  made. 
Briefly  speaking,  when  your  patient  goes  away  from  this  examination, 
he  ought  to  feel  himself  laid  bare  physically  as  he  had  been  psychi- 
cally. It  will  sometimes  happen  in  the  course  of  this  examination  that 
you  will  discover  somewhere  some  organic  defect.  It  will  then  give  you 
the  key  to  many  of  the  added  phenomena  for  which  otherwise  you 
have  had  no  explanation.  You  must  not  conceal  the  existence  of  this 
trouble  from  the  patient.  Above  all,  you  must  not  stoutly  maintain 
that  there  is  nothing  the  matter  when  there  is  something  the  matter.  By 
wishing  to  cure  him  completely,  you  will  not  cure  him  at  all. 

On  the  other  hand,  you  must  conduct  this  examination  ii;  such  a 
way  that  it  does  not  make  any  strong  impression  on  your  patient.  It 
is  a  useful  way  to  give  the  impression  that  you  are  making  this  examina- 
tion because  you  wish  to  do  your  work  conscientiously,  and  not  because 
you  suspect  him  to  have  some  serious  affection.     In  case  of  need,  as 


EXAMINATION  AND  QUESTIONING  OF  NEUROPATHS.    291 

you  proceed  with  this  examination,  in  order  to  avoid  raising  any  terrify- 
ing doubts  in  your  patient's  mind,  you  may  assure  him  of  the  healthy 
condition  of  such  an  organ  or  the  proper  functioning  of  such  a  function 
which  you  have  just  examined. 

But  here,  on  the  part  of  the  examiner  as  well  as  for  the  one  ques- 
tioned, there  must  be  nothing  kept  back,  and  nothing  passed  over  in  a 
mysterious  way.  In  other  words,  once  this  examination  is  finished,  there 
must  be  a  complete  sense  of  confidence  between  yourself  and  your  pa- 
tient, and,  just  as  he  has  hidden  nothing  from  you,  in  the  same  way 
you  must  keep  back  nothing  from  him  concerning  his  condition. 

You  have  thus  brought  yourself  into  perfect  touch  with  your  patient. 
You  know  him  psychically,  morally,  and  physically  as  well  as  if  you 
had  lived  side  by  side  for  years.  Then  and  then  only  you  will  have  the 
right  to  undertake  the  therapeutic  part  of  your  work.  This,  if  you  have 
hitherto  followed  the  line  which  we  have  just  indicated,  will  be  remark- 
ably simplified. 

To  approach  the  subject  in  this  way  will  evidently  take  some  time. 
You  will  perhaps  be  obliged  to  take  it  up  on  several  different  occasions, 
in  case  your  patient,  or  you  yourself,  become  fatigued.  That  does  not 
matter;  the  time  is  not  lost.  The  key  to  success  in  psychotherapy  is 
found  in  a  clear  and  primitive  comprehension  of  things.  And  we  say 
absolutely,  to  those  who  do  not  know  how  or  have  not  the  patience  to 
work  in  this  manner,  that  they  have  no  right  to  judge  the  value  of  psy- 
chotherapy by  persuasion.  If  in  their  hands  it  shows  but  very  little 
good  result,  it  is  because  they  have  not  given  time  enough  tb  their 
patients  to  cure  them. 


CHAPTER  XXL 

THE  MORAL  AND  MENTAL  SUBSTRATUM.      ITS  PSYCHOTHERAPY. 

At  the  very  start  of  this  study  we  must  make  a  distinction.  Neuras- 
thenia and  hysteria,  as  we  have  seen,  are  accompanied  by  very  different 
mental  and  moral  conditions.  Their  therapy,  therefore,  cannot  be  con- 
sidered from  the  same  point  of  view.  So  we  shall  take  up  successively 
the  neurasthenic  and  the  hysteric. 

In  order  thoroughly  to  understand  the  real  mental  and  moral  con- 
dition of  the  neurasthenic,  it  seems  to  us  necessary  to  state  a  few  pre- 
liminary ideas.  All  the  phenomena  of  life  may  be  classified  in  a  certain 
number  of  phases  which  one  might  sum  up  as  follows  :  First,  stimulus, 
whether  of  external  origin  or  called  up  by  internal  emotion.  Then,  the 
phase  of  consciousness;  where  the  subject,  thanks  to  his  intellectual 
control,  is  able  to  judge  the  nature  of  the  stimulus  which  he  has  felt. 
Then,  the  phase  of  appreciation,  if  one  might  so  call  it,  where  the  im- 
pressions, having  had  no  intellectual  quality  in  any  absolute  way,  take 
on,  by  reason  of  their  relation  to  the  personality  of  the  subject,  a 
relative  value.  Finally,  the  phase  of  reaction  of  the  personality,  which 
may  or  may  not  manifest  itself  in  the  form  of  action.  Stimulus  and  re- 
ception, comprehension  or  judgment  constitute  passive  phenomena  in 
which  only  those  qualities  of  stimulus  submitted  to  the  intellectual 
faculties  of  the  subject  come  into  play.  This,  in  a  word,  is  the  phase  of 
consciousness.  In  the  normal  subject,  the  personality  only  comes  in  a 
secondary  way  to  judge  the  relative  value  of  the  consciousness  thus 
acquired,  to  adopt  it,  without  any  reaction,  if  one  feels  practically  in- 
different to  it,  or,  if  not,  to  proceed  to  adapt  one 's  self  to  it. 

In  learning  any  fact  whatsoever,  we  look  at  it  first  intellectually, 
under  its  various  aspects,  we  register  it  in  our  memory,  merely  as  a 
simple  phenomenon  of  consciousness,  if  it  can  neither  hurt  us  nor  be 
of  use  to  us.  If  we  find  that  it  is  going  to  be  useful  to  us  in  some  way, 
we  receive  it  into  our  personality,  whose  general  direction  may  be 
modified  by  it.  If  it  is  harmful  to  us,  and  if  we  have  adjudged  it 
intangible,  we  force  ourselves  to  change  our  ideas  and  adapt  ourselves 
to  it.  If,  on  the  other  hand,  we  judge  that  we  may  have  some  power,  if 
not  over  the  fact,  at  least  over  its  consequences,  we  make  an  effort,  by 
various  reactions,  to  act  directly  either  on  the  fact  or  on  its  consequences. 

This  is  the  manner  in  which  a  person  who  is  quite  morally  and  men- 
tally sane  will  act.  In  such  a  subject,  by  reason  of  his  judgment,  which 
has  hitherto  been  purely  intellectual,  the  reactions  of  the  personality  are 
in  fact  reduced  to  a  minimum,  and  the  adaptation  to  the  case  in  hand 
will  be,  moreover,  all  the  more  easy  in  proportion  as  the  intellectual 
292 


MORAL  AND  MENTAL  SUBSTRATUM.        $  293 

appreciation  will  have  been  more  perfect  and  complete.  In  order  to 
fight  an  enemy,  according  to  the  common  formula,  the  important  thing 
is,  first  of  all  to  know  him,  to  know  the  forces  that  he  has  at  his  dis- 
position, the  groimd  on  which  he  will  develop  his  plans,  and  the  side 
on  which  he  will  probably  attack.  In  fact,  the  man  who  is  to  be  vic- 
torious, from  this  complete  point  of  view,  is  the  one  who,  before  per- 
forming any  action,  and  before  permitting  anything  to  come  into  his 
personality,  is  able  to  look  upon  things  objectively,  to  consider  them 
as  if  they  had  nothing  to  do  with  him,  and  to  forget  for  the  moment 
that  he  is  to  judge  them. 

As  a  matter  of  fact,  this  ideal  individual  does  not  exist  in  nature, 
except  in  a  very  small  number  of  instances,  and  the  one  who  is  un- 
doubtedly the  furthest  removed  from  this  ideal  is  the  actual  or  virtual 
neurasthenic. 

When  one  speaks  of  the  emotional  or  constitutional  neurasthenic, 
one  does  not  merely  allude  to  the  various  reactions  which,  with  a  more 
or  less  specific  individuality,  he  is  likely  to  show  in  physical  life.  The 
neurasthenic  has  in  addition  to  that  a  very  great  moral  emotivity.  The 
latter  is  measured  by  the  precocious  and  too  interested  intervention  of 
the  personality,  even  in  the  very  cases  where  it  would  seem  a  priori  that 
it  ought  to  be  indifferent.  When  one  says  that  the  neurasthenic  takes 
things  too  much  to  heart,  that  he  considers  almost  everything  of  almost 
equal  importance,  one  does  not  mean  by  that  that  he  has  no  perception 
of  intellectual  value.  The  most  subtle  problem  of  geometry  might  be 
solved  by  a  neurasthenic,  or  the  most  charming  description  be  written 
by  him.  One  only  means  to  say  that  he  does  not  know  how  to  interpose 
between  the  various  events  which  may  affect  him — even  without,  as  a 
matter  of  fact,  touching  him  or  having  any  reaction  on  his  personality — 
sufiicient  time  to  allow  for  a  purely  speculative  examination  of  things. 
His  personality  comes  into  play  although,  intellectually  speaking,  the 
phenomena  in  question  are  barely  subconscious.  It  is  naturally  evident 
that,  as  he  cannot  adapt  himself  to  things  which  he  does  not  know,  the 
reactions  of  his  personality  will  be  diffuse  and  more  or  less  incoherent. 
They  will  be  expressed  in  this  way  by  hesitations  in  decisions,  scruples, 
and  finally  by  preoccupations.  In  other  words,  the  degree  of  the  per- 
sistence and  of  the  utilization  of  intellectual  control  will  measure  the 
degree  and  the  absolute  value  of  personal  reactions.  Under  insufficient 
intellectual  control,  the  reactions  must  of  necessity  be  non-adapted  or 
non-adaptable,  and  mental  phenomena,  and  more  especially  moral 
phenomena,  will  result  from  the  consciousness  of  this  non-adaptation. 
Feelings  of  insecurity,  and  incompletion,  to  employ  Janet's  expression, 
slight  and  diffused  phenomena  of  anxiety,  and  a  feeling  of  helplessness 
and  failure,  will  occur.  It  goes  without  saying,  that,  step  by  step,  the 
neurasthenic,  perceiving  his  inability  to  react  usefully,  will  derive  from 
this  a  general  conception  of  psychic  and  moral  depression,  and  a  sort 


294      THE  TREATMENT  OF  PSYCHONEUROSES. 

of  experimental  pessimism.  All  these  feelings  of  insufficiency  that  the 
neurasthenic  has  are,  therefore,  not  purely  illusory,  but  spring  simply 
from  a  bad  psychical  and  moral  hygiene. 

We  must  now  ask  ourselves,  what  are  the  elements  which  may  con- 
tribute thus  to  weaken  the  intellectual  control  of  people?  We  already 
know  the  majority  of  them.  /- 

We  have  seen  in  connection  with  this  that  certain  emotional  causes, 
by  the  very  intensity  of  their  action  and  the  suddenness  of  their  onset, 
could  not  possibly  be  immediately  or  even  rapidly  adapted.  We  have 
also  developed  elsewhere  the  idea  that,  just  as  certain  subjects  possess 
specific,  psychic  emotivity,  so  in  their  personality  there  are  zones  that 
are  peculiarly  sensitive  to  the  emotional  excitation  which  may  affect 
them. 

The  fact  still  remains,  however,  that  there  are  people  who  are  con- 
stitutionally of  a  restless  nature,  who  are  in  a  condition  of  subcontinuous 
emotionalism,  and  who  for  this  reason  weaken  by  means  of  their  internal 
activity  the  value  of  their  intellectual  control.  All  external  phenomena 
become  factors  of  emotion  for  them,  because,  living  a  too  exclusively 
internal  life,  without  any  especial  religious,  moral,  philosophical,  or 
practical  direction  which  is  sufficiently  intense  to  inhibit  stimuli  of 
external  origin,  these,  when  they  occur,  take  them  by  surprise,  and 
trouble  them  because  they  are  never  prepared  for  them. 

Then  there  are  all  the  vanquished  ones  of  life,  who,  having  struggled 
against  circumstances  for  months,  or  perhaps  years,  have  not  been  able 
to  triumph  over  them.  They  are  in  a  defiant  state  themselves,  in  a  state 
of  subcontinuous  restlessness.  But  this  has  nothing  to  do  with  any 
constitutional  defect.  They  fail  to  use  their  intellectual  control,  just  as 
they  would  neglect  to  use  some  instrument  whose  inaccuracy  or  poor 
condition  had  been  experimentally  proved  to  them.  For  these  in- 
dividuals, the  lack  of  intellectual  control  constitutes  a  true  reaction  of 
abandon,  a  confession  of  defeat.  Henceforth  these  subjects  will  allow 
themselves  to  be  borne  along  by  events,  and  the  only  reactions,  or  as  we 
have  described  the  non-adaptations,  which  they  will  present  will  come 
from  the  onset  of  external  stimuli  against  their  personality,  which  is 
here  completely  subconscious  and  no  longer  voluntarily  able  to  act. 
But  these  subjects  do  not,  properly  speaking,  become  neurasthenics. 
They  are  the  wastes  of  life,  and,  when  the  reaction  of  abandon  is  abso- 
lutely complete,  so  much  so  that  they  no  longer  make  any  attempt  or 
any  struggle  toward  adaptation,  the  various  phenomena  of  the  neuras- 
thenic state  cannot  follow,  and  this  is  in  accordance  with  the  conception  we 
have  given  of  this  psychoneurosis.  In  order  for  a  subject  to  present  fully 
the  usual  complete  mental  and  moral  condition  of  the  neurasthenic,  he 
must  needs  have  more  or  less  lost  his  intellectual  control,  but  he  must  also 
be  in  the  position  of  trying  to  recover  his  self-control. 

In  reality,  the  etiological  factor  which  seems  to  us  important,  and 


MORAL  AND  MENTAL  SUBSTRATUM.  295 

from  which  results  the  participation  of  the  intimate  personality  in  a 
whole  series  of  facts  which  ought  to  be  foreign  to  it,  such  as  the  inter- 
vention of  the  subconscious  in  phenomena  which  ought  normally  only 
to  depend  upon  the  consciousness,  the  essential  thing  is  the  lack  of 
general  direction. 

The  personality — ^the  subconsciousness,  if  one  prefers  it — is  con- 
tinually, so  to  speak,  overflowing  the  phenomena  of  consciousness,  es- 
pecially so  if  the  subconscious  is  not  dammed  by  the  power  of  the 
general  idea,  or  if  the  whole  personality  is  not  tending  toward  the 
accomplishment  of  some  end  or  the  satisfaction  of  an  ideal.  The  in- 
dividual who  knows  what  he  wants  and  where  he  wants  to  go,  the  man 
to  whom  some  religious  or  philosophical  idea  serves  as  a  guide,  the 
person  who  simply  directs  this  or  that  affective  tendency,  the  subject, 
in  fact,  who  in  order  to  determine  upon  some  line  of  life  trusts  himself 
absolutely  to  some  leader  or  director  of  conscience, — ^such  a  man  cannot 
become  a  neurasthenic.  Wjhether,  like  a  child  accompanied  by  his 
parents,  or  like  a  soldier  who  trusts  in  his  chief,  he  merges  his  per- 
sonality, or  whether  the  personality  is  in  some  way  externalized  toward 
an  ideal,  the  result  is  the  same  ;  the  individual  has  moral  support. 

In  this  respect  two  classes  of  patients  should  be  mentioned.  There 
are  those  who,  by  reason  of  education  or  by  their  constitutional  insuffi- 
ciency, have  never  been  able  to  direct  themselves  in  this  way.  There  are 
others  who,  on  account  of  some  external  cause,  have  lost  this  orienta- 
tion. If  the  end  toward  which  they  are  working  is  suddenly  withdrawn 
or  becomes  intangible,  if  the  affection  in  which  they  were  trusting  has 
disappeared,  if  the  ideal  which  has  guided  and  upheld  them  is  suddenly 
destroyed,  then,  but  then  only  when  completely  broken  down,  are  they 
susceptible  of  becoming  neurasthenics.  Our  experience  shows  us  many 
such  examples  every  day.  The  priest  who  has  lost  his  faith,  the  ambitious 
man  who  has  been  definitely  supplanted,  the  lover  who  has  been  dis- 
missed,— all  these  are  in  a  fair  way  to  become  patients.  It  must  also 
be  added  that,  most  undoubtedly,  any  religious  or  philosophical  ideal, 
particularly  in  the  shadow  of  human  vicissitudes,  gives  quite  another 
kind  of  strength  from  that  which  comes  with  the  pursuit  of  some  real 
or  material  aim. 

However  it  may  be,  the  characteristic  thing  about  the  neurasthenic — 
whether  it  is  constitutional  or,  as  more  often  happens,  accidental — is  his 
disoriented  personality.  His  intellectual  control  is  singularly  weakened 
by  it,  and  various  manifestations  of  the  psychoneuroses  follow  almost 
at  once,  such  as  restlessness,  a  feeling  of  insecurity  and  pessimism,  which, 
as  a  fact,  is  nothing  but  the  expression  of  absence  of  direction  and  lack 
of  any  aim. 

In  former  times  the  emotions  were  catalogued  differently  and  divided 
into  asthenic  or  depressing  emotions  and  sthenic  or  strengthening 
emotions.    This  division  seems  to  us  to  exist  still,  and  at  the  same  time 


296      THE  TREATMENT  OF  PSYCHONEUROSES. 

it  has  great  therapeutic  interest  to  us.  Nevertheless,  we  must,  first  of 
all,  understand  just  what  one  means  by  a  depressing  emotion  or  a  sthenic 
emotion.  According  to  our  way  of  thinking,  an  emotional  stimulus  has 
no  intrinsic  value.  One  cannot  say  a  priori  that  an  emotion  of  such  or 
such  a  nature — ^with  certain  exceptions,  of  course — will  necessarily  ex- 
ercise a  stimulating  or  a  depressing  action  on  every  individual.  Good 
news  may  under  certain  conditions  have  a  depressing  action,  and,  on 
the  contrary,  bad  news  may  be  strengthening.  We  may  perhaps  at 
this  point  of  our  study  explain  our  meaning  on  this  point  more  easily. 
It  is  evident  that  one  might  consider  depressing  any  emotion  which 
would  tend  to  dislocate  or  disorient  the  personality,  and  that  one  could, 
on  the  other  hand,  regard  as  sthenic  all  emotional  action  which  will 
react  in  the  sense  of  the  reorientation  or  the  most  complete  orientation 
of  the  personality.  Therefore,  as  far  as  the  mental  and  moral  foundation 
of  the  neurasthenic  is  concerned,  the  therapeutic  action  of  a  strengthen- 
ing emotion  seems  to  us  absolutely  preponderant, — we  might  almost  say 
the  only  one  to  act. 

Quite  apart  from  any  therapeutic  action,  one  sometimes  sees  sub- 
jects who  are  more  or  less  profoundly  neurasthenic  and  who  on  finding 
themselves  suddenly  in  the  presence  of  some  new  situation  completely 
forget,  under  the  influence  of  emotional  excitement,  that  they  are  neuras- 
thenic, and  almost  immediately  recover  their  mental  and  moral  health. 
Emotional  stimulation  has,  in  fact,  exercised  a  synthetic  action  of 
orientation  on  the  personality  of  the  subject.  Having  found  an  object 
in  life,  he  has  ceased  to  be  neurasthenic.  Physicians  may  not  perhaps 
often  have  opportunity  to  observe  facts  of  this  kind,  but,  if  one  looks 
around  one  in  daily  life,  one  sees  them  all  the  time.  We  all  know  people 
who  were  on  the  verge  of  becoming  neurasthenic — ^who,  as  a  matter  of 
fact,  as  far  as  their  symptoms  were  concerned,  were  already  neurasthenic 
— and  whom  some  emotional  excitement  had  put  upon  their  feet.  The 
rareness  of  such  cases — which  is,  however,  purely  apparent — lies  in  the 
fact  that  the  physician  so  seldom  sees  neurasthenics  at  the  beginning  of 
the  development  of  their  disease,  and  that  he  seldom  comes  in  contact 
with  these  patients  until  after  symptoms  of  every  kind  have  occurred 
which  modify  the  aspect  of  the  trouble. 

Is  it  possible  that  such  subjects  have  realized  the  benefit  of  a  re- 
storative emotion,  or  because  they  have  previously  gone  through  some 
long  process  of  reasoning?  Certainly  not.  Phenomena  of  this  kind 
take  place,  as  do  the  phenomena  of  the  upsetting  emotion,  in  the  sub- 
conscious. The  individual  is  not  aware  of  it.  He  gets  hold  of  himself 
first  and  reasons  afterward.  It  seems  to  us,  speaking  from  the  thera- 
peutic point  of  view,  that  it  is  rather  illogical  to  think  that  subjects 
who  are  known  to  have  lost  some  of  their  intellectual  control,  and  who 
are  subject  to  exaggerated  emotional  reactions,  can  be  benefited  by 
reason  if  sthenic  emotion  can  do  nothing.     It  also  seems  to  us  tha.t 


MORAL  AND  MENTAL  SUBSTRATUM.  297 

psychotherapy  ought,  if  it  wishes  to  modify  the  mentality  and  morale 
of  its  patient,  to  address  itself  almost  solely  to  the  feelings,  and  very 
rarely  approach  the  high  summits  of  pure  reason.  If  the  neurasthenic 
condition  comes  on  at  the  time  when  emotion  has  overthrown  the  reason, 
it  does  not  seem  to  us  quite  logical  to  infer  that  a  course  of  reasoning* 
will  be  the  best  therapeutic  measure  to  help  the  patient  to  re-establish 
the  balance  of  his  reason. 

Does  that  mean  to  say  that  we  do  not  consider  that  reasoning  has 
any  value?  We  do  not  mean  to  go  so  far  as  that.  We  think,  on  the 
other  hand,  that,  at  least  as  far  as  all  the  functional  manifestations  are 
concerned, — even  in  cases  which,  Hke  certain  phobias,  are  of  a  purely 
mental  nature, — it  is  necessary  to  furnish  the  patient  with  such  a  clear 
explanation  of  things  that  he  may  himself  get  an  exact  idea  of  them. 

But,  as  far  as  the  moral  depth  of  the  neurasthenic  is  concerned,  we 
frankly  do  not  think  that  general  considerations  of  an  ethical  nature 
have  ever  directly  modified  it.  On  the  other  hand,  the  neurasthenic  in 
all  that  concerns  his  condition  hardly  ever  rises  above  his  particular 
case.  He  is  quite  able  to  appreciate  the  beauty  of  one's  argument,  but 
he  does  not  think  of  applying  it  to  himself  and  he  does  not  attribute 
any  immediate  therapeutic  value  to  it.  In  psychotherapy  reasoning  is 
indifferent.  But  what  does  do  good  is  the  confidence  which  can  be  in- 
spired in  a  patient  by  a  physician  whom  he  feels  to  be  morally  and 
intellectually  his  superior,  and  the  value  of  the  reasoning  lies  wholly  in 
the  impression  of  confidence  and  security  introduced  into  the  mentality 
of  the  patient,  who,  feeling  himself  in  good  hands,  finds  himself  com- 
forted and  strengthened.  In  such  cases  we  are  reminded  of  the  words 
of  Pascal,  '  '  The  heart  has  reasons  which  reason  never  knows.  '  ' 

It  would,  in  fact,  be  too  naïve  to  believe  that  the  psychotherapist 
has  at  his  disposition  a  method  of  special  reasoning,  and,  unknown  to 
any  one  but  himself,  a  specially  convincing  lingo.  It  is  the  confidence 
which  he  inspires  and  his  manner  of  saying  things  which  are  the  cause 
of  his  success.  More  than  once  we  have  heard  patients  make  the  follow- 
ing remark:  "It  is  very  curious,  doctor;  I  have  already  been  told  prac- 
tically the  same  thing  as  you  have  told  me,  and,  although  I  have  under- 
stood it,  yet  I  have  not  been  convinced."  ''And  why?"  we  ask  them. 
The  reply  is  always  the  same:  ''I  did  not  feel  any  confidence  in  the 
others,  but  with  you  it  is  quite  different."  The  whole  explanation  of 
the  results  of  psychotherapy  lies  in  this  reply.^ 

^  An  indication  of  the  rôle  which  confidence  plays  in  the  treatment  by  psycho- 
therapy lies,  as  one  of  us  has  already  shown,*  in  the  difference  which  exists  in  the 
length  of  time  required  for  the  treatment  according  to  whether  the  case  is  in  private 
practice  or  in  the  hospital.  The  neuropaths  whom  we  treat  by  the  method  of 
isolation  at  the  Salpêtrière,  in  the  Pinel  Ward,  come  to  us,  for  reasons  which  it  is 
easy  to  understand,  in  a  much  more  serious  condition — for  they  have  struggled  to 

*  J.  Dejerine:  "  L<e  Traitement  des  psychoneu roses  a  l'Hôpital  par  la  méthode  de 
isolement,"  Revue  Neurologique,  1902,  p.  1145. 


298      THE  TREATMENT  OF  PSYCHONEUROSES. 

It  is  clear,  from  what  we  have  just  said,  that  the  first  work  of  the 
psychotherapist  should  be  to  reconstruct  his  patient's  personality,  and 
in  order  to  accomplish  this  reconstruction  he  will  have  to  depend  almost 
entirely  upon  the  sthenic  emotions.  How  should  he  begin  this  under- 
taking ? 

A  very  thorough  knowledge  of  his  patient's  personality  and  life  is 
evidently  absolutely  necessary  for  him,  in  order  to  know  with  any 
degree  of  certainty  what  chords  are  likely  to  respond,  and  how,  starting 
from  this  point,  he  may  synthetically  build  up  the  disintegrated  per- 
sonality. But,  first  of  all,  there  is  a  very  general  rule  which  does  not 
require  any  very  profound  questioning.  As  a  secondary  consideration, 
but  one  that  is  nevertheless  very  effective,  is  the  very  fact  of  his  disease, 
which  has  been  and  which  still  is  a  cause  of  continued  emotion  to  the 
patient,  exaggerating  pre-existing  phenomena,  or  at  least  assuring  their 
continuity.  If,  as  the  result  of  your  questioning  and  physical  examina- 
tion, you  feel  quite  sure  of  the  purely  functional  nature  of  all  the 
troubles  presented  by  your  subject,  you  ought  to  assure  him  at  the 
start  of  the  certainty  of  being  able  to  cure  him,  and  to  tell  him  ap- 
proximately how  much  time  it  would  take.  One  could  hardly  believe 
how  much  power  there  is  in  a  simple  statement  of  this  kind,  made  by  a 
physician  who  has  his  patient's  confidence,  in  helping  to  change  rapidly 
and  completely  the  patient's  moral  condition.  We  have  seen  patients 
who  have  been  ill  for  years,  and  who,  at  the  simple  idea  that  in  a  few 
weeks  or  even  a  few  months  they  would  recover  their  physical  and 
psychic  health  and  personality,  were  overcome  by  intense  emotion,  which, 
however,  was  peculiarly  helpful  to  them.  "We  have  known  some  for 
whom  this  conviction  of  the  immediate  prospect  of  a  cure  was  alone  suffi- 
cient so  to  change  the  current  of  their  thought  that  they  were  able  to 
begin  to  plan  and  make  decisions,  and  were  in  some  respects  cured  even 
before  their  treatment  had  begun.    Is  this  the  result  of  reasoning?    Cer- 

the  end  of  their  power — than  the  patients  of  the  richer  or  more  comfortable  classes. 
Nevertheless,  they  are  cured  more  quickly,  on  the  average,  than  the  latter.  The 
reason  for  this  is  as  follows:  These  subjects,  who  are  quite  as  intelligent  and  often 
have  much  better  sense  than  society  people,  have  been,  first  of  all,  less  spoiled  by 
their  physicians,  and  they  have  a  much  more  lofty  idea  of  the  power  of  the  head 
physician  of  the  hospital;  but  that  is  not  the  principal  reason.  It  is  the  surround- 
ings which  here,  first  of  all,  create  the  atmosphere  of  confidence.  In  the  first  place, 
the  statement  that  they  will  get  well  is  made  publicly,  before  a  more  or  less  con- 
siderable number  of  students,  thus  starting  off  under  such  conditions,  which  are 
quite  different  from  those  which  one  finds  either  in  the  doctor's  office  or  in  the 
private  room  in  a  hospital,  where  the  conversation  takes  place  alone,  without  any 
witnesses  present.  Patients  in  private  practice  have  often  said  to  us  after  a  few 
weeks  of  treatment  :  "  Now,  doctor,  I  am  convinced  ;  but  I  must  confess  to  you  that 
at  first  I  could  hardly  say  as  much,  because  I  have  been  told  so  many  times  before 
that  I  would  be  cured." 

In  our  hospital  practice  it  has  happened  more  than  once  to  one  of  us,  that, 
after  one  or  two  consultations  in  public  before  the  visiting  consultants  of  the 
Salpêtriêre,  we  have  been  able  completely  and  definitely  to  cure  intense  pains  of 
various  kinds  which  dated  back  several  years.  When,  afterward,  we  have  asked 
these  patients  how  and  why  the  faith  in  their  cure  had  come  to  them,  their  re- 


MORAL  AND  MENTAL  SUBSTRATUM.  299 

tainly  not.  It  is  the  simple  introduction  into  the  patient's  mind,  but 
this  time  with  a  feeling  of  certainty,  of  something  which  until  then  he 
had  scarcely  dared  to  think  of  as  possible.  This  idea,  independent  of 
all  new  medical  action,  continues  its  strengthening  action,  because  there 
have  appeared  with  it  such  elements  as  faith,  hope,  and  confidence, 
which,  although  having  almost  no  intellectual  value,  yet  have  consider- 
able emotional  power. 

The  second  psychotherapeutic  action  which  the  physician  will  have 
to  exercise  will  be  what  we  might  call  a  liberating  action.  Many  pa- 
tients entertain,  along  with  their  many  other  causes'  of  moral  depression, 
feelings  of  scruple,  remorse,  and  self-reproach.  Such  a  one  will  be 
greatly  worried  because  on  account  of  his  illness  he  cannot  support  his 
family  and  provide  for  the  future  of  his  children.  Another  will  have 
played  some  responsible  part  in  some  great  moral  or  business  catastrophe, 
and  lives  in  the  idea  that  the  harm  that  was  done  is  irreparable.  This 
one  will  reproach  himself  because  he  has  deceived  his  wife,  because  he 
has  hidden  from  her  the  fact  that  he  has  a  natural  child.  .  .  .  One  could 
hardly  believe  how  many  and  how  strange  are  the  sorrowful  secrets 
which  cause  a  feeling  of  moral  depression  in  many  patients. 

The  building  up  and  the  redirecting  of  the  personality  of  the  neuras- 
thenic cannot  be  begun  until  the  patient  has  got  to  the  point  where  he 
is  ready  to  sweep  away  all  these  continued  emotional  causes  which  are 
the  factors  of  the  persistence  of  his  condition.  Now,  we  do  not  deny 
that  here  reasoning  will  have  considerable  effect.  Evidently  the 
physician  will  do  right  to  point  out  to  his  patient  how  much  his  pre- 
occupations and  reproaches  and  remorses  are  exaggerated,  and  in  all 
cases  how  useless  they  are.  It  will  be  his  duty  to  tell  him  that  the  best 
method  in  his  power  to  restore  his  health  is  to  consider  the  past  as  behind 
him,  and  to  start  afresh  with  new  courage.  But  the  thing  which  above 
all  has  liberating  action,  giving  a  sense  of  freedom,  is  the  act  of  con- 

sponse  was  invariably  the  same  :  "  At  first  I  was  so  stupefied  at  hearing  that  there 
was  no  lesion  in  the  case  and  that  in  order  to  get  rid  of  my  pain  I  only  had  to 
doubt  that  I  had  it,  that  when  I  went  away  I  said,  *  This  doctor  has  not  seen 
through  my  case  at  all.'  Then,  on  reflection,  I  said  to  myself  that  it  would  be 
impossible  for  a  physician  surrounded  by  such  a  great  number  of  students  to  be 
other  than  a  very  able  man.  It  was  in  this  way  that  there  was  bom  in  me  con- 
fidence in  the  certainty  of  my  cure."  We  have  taken  this  example  of  pains  because 
this  has  to  do  with  one  of  the  neuropathic  manifestations  which  is  often  the  most 
rebellious  and  the  most  difficult  to  cure;  we  do  not  count,  as  a  matter  of  fact,  the 
numerous  false  gastropaths,  false  enteropaths,  false  cardiacs,  false  urinaries,  etc., 
which  we  have  cured  under  the  same  conditions, — ^that  is  to  say,  after  one  or  two 
conversations  in  public. 

There  is  still  another  reason  why  so  many  neuropaths  are  cured  more  quickly 
in  the  hospital  than  in  private  practice,  and  that  is  because  in  the  isolation  hall 
there  are  patients  who  are  more  or  less  advanced  in  their  cure,  and  whose  presence 
gives  confidence  to  the  new-comers.  Then,  again,  patients  who  have  been  cured  for 
a  greater  or  less  length  of  time  often  for  several  years  sometimes  come  back  to 
pay  a  visit  to  the  director,  and  are  shown  to  those  in  the  ward.  All  these  are 
elements  which  rapidly  bring  a  feeling  of  confidence  in  the  cure,  and  which  are 
naturally  lacking  in  private  practice. 


300      THE  TREATMENT  OF  PSYCHONEUROSES. 

fession  itself.  All  the  physician's  efforts  ought  to  be  directed  to  this 
when  he  feels  *  *  that  there  is  something  there.  "  It  is  the  emotional  con- 
dition which  the  confession  brings  about  that  exercises  its  stimulating 
action  in  such  cases,  and  they  were  profound  psychologists  who  in- 
stituted confession  as  an  important  religious  practice.  It  is  commonly 
said  that  a  sin  confessed  is  half  pardoned.  We  frankly  say  that  one 
pardons  one's  own  fault  when  one  has  confessed  it.  And  it  is  this 
liberating  action  which  the  physician  should  first  of  all  seek.  It  is  in 
some  way  accomplished  independently  of  him,  once  he  has  been  able  to 
call  forth  the  confession,  and  the  rôle  which  reason  plays  is  here,  if  not 
wholly  negative,  at  least  of  purely  relative  importance. 

Here,  then,  we  have  a  patient  believing  in  the  possibility  of  a  normal 
future  as  soon  as  he  believes  in  his  cure,  and  relieved  of  a  great  weight 
upon  his  conscience  by  the  act  of  confession.  The  part  that  the  psycho- 
therapist has  to  play  by  no  means  ends  here,  although  such  an  important 
part  has  already  been  accomplished.  The  physician  has  realized  the 
conditions  which  will  permit  his  patient's  personality  to  be  directed 
again  into  healthy  channels.  It  is  the  idea  of  this  orientation  and  the 
general  direction  which  the  patient  must  take  that  he  must  now  lay 
down  for  him.  No  future  can  be  established  in  the  air.  If  under  some 
circumstances  the  personality  of  the  patient  has  spontaneously  taken  its 
former  direction,  yet  in  a  great  many  cases,  where  the  disintegrating 
action  has  been  sufficiently  profound,  this  is  not  the  case  ;  there  are  also 
a  great  many  subjects  who  have  become  neurasthenic  for  the  very 
reason  that,  to  a  greater  or  less  degree  by  the  tragedy  of  life,  the  very 
things  which  form  the  basis  of  their  life's  work  have  disappeared. 

It  is  just  here  that  the  tact  of  the  psychotherapist  comes  into  play. 
We  lay  it  down  as  a  principle  that  at  this  period  of  treatment  it  is  in 
the  very  personality  which  the  patient  has  previously  had  that  one  must 
look  for  the  elements  of  direction  and  re-orientation  of  his  personality 
and  of  his  life.  When  one  has  to  deal  with  subjects  whose  intellectual 
control  is  weak,  and  who,  having  confidence  in  their  physicians,  are  as 
a  result  often  very  much  disposed  to  take  everything  that  they  say  as 
an  article  of  faith,  we  do  not  feel  that  one  has  the  right  to  impose  one's 
own  way  of  looking  at  things  and  the  understanding  of  existence.  The 
power  of  reasoning  in  these  patients  is  much  more  destructive  than 
creative.  By  attempting  to  lay  down  any  philosophical  theory  or  direct* 
ing  action  on  the  patient,  one  would  risk  distracting  or  destroying  the 
elements  which  when  awakened  are  capable — such  as  religious  faith,  for 
example — of  exercising  the  most  marvellous  curative  action  upon  him. 
Such  an  action  would  leave  the  patient  more  unbalanced  and  disoriented 
than  ever. 

It  is  only  necessary,  we  feel,  to  touch  the  chords  which  have  hitherto 
been  responsive.  Thus  and  thus  only,  and  not  by  deductive  reasoning, 
but  by  the  simple  indication  which  becomes  for  the  patient  the  starting* 


MORAL  AND  MENTAL  SUBSTRATUM.  301 

point  of  sthenic  emotion,  the  old  personality,  which  had  actually  fallen 
to  pieces,  may  be  built  up  again.  You  are,  we  will  suppose,  treating 
a  patient  whose  life  has  been  given  over  to  altruistic  deeds,  who  is 
devoted  to  a  mother,  to  a  wife,  or  to  children,  and  whose  neurasthenic 
condition  has  been  caused  either  by  some  affective  disillusion  or  by  the 
death  of  some  being  who  has  been  the  object  of  all  his  preoccupation.  It 
is  to  these  general  affective  tendencies  that  you  must  direct  yourself. 
You  must  know  how  to  make  him  understand  that  others  wiU  exist  for 
him,  and  that  there  will  be  other  work  which  will  claim  his  activity.  If 
need  be,  by  examining  very  carefully  the  life  of  your  patient  and  the 
way  he  acts,  you  may  attempt  to  go  into  detail  with  a  little  more  definite 
plan.  You  will  in  this  way,  by  creating  an  emotiqn  in  him  which  is 
sthenic  because  it  conforms  to  his  former  tendencies,  call  forth  the  most 
constructing  and  uplifting  sense  of  action.  But  your  personality  and 
your  conception  of  life  and  of  things  must  on  no  account  enter  into  it, 
because  it  has  no  right  to  do  so.  Your  function  will  only  be  to  under- 
stand your  patient. 

Here  is  another  who  has  a  strong  religious  belief.  Do  not  hesitate 
to  tell  him  to  trust  to  it.  Here  is  another  who  is  an  ambitious  man,  who 
has  failed  in  his  ambition.  Try  to  make  him  understand  the  possibility 
of  turning  his  ambition  toward  some  other  end.  And  even  if  you  find 
another  who  is  a  high  liver  and  a  materialist — though  such  people  very 
rarely  become  neurasthenic — it  is  right  for  you  to  tell  him  to  take  all 
that  life  may  have  still  in  store  for  him  in  the  pleasures  which  he  prefers. 

Later,  when  your  patient  is  once  cured  and  returned  to  his  former 
condition,  if  you  think  that  he  has  an  unhealthy  and  dangerous  point  of 
view  as  regards  life,  you  may,  and  you  even  ought  to  enter  into  a  dis- 
cussion with  him,  and  draw  out  from  him  the  inconveniences  or  the  lack 
of  logic  in  his  way  of  looking  at  things,  or  of  behaving  himself.  When 
you  get  to  that  point,  you  will  stand  shoulder  to  shoulder  with  your  pa- 
tient, and  you  will  then  need  have  no  fear  about  adding  to  his  doubts 
or  his  depressing  uncertainties.  You  will  run  no  risk  of  postponing  his 
cure  by  wanting  to  make  it  too  complete.  When  you  get  to  this  point, 
but  only  then,  you  may  assume  the  rôle  of  the  moralist. 

Even  for  the  individuals  whose  ideas  are  directly  responsible  for  the 
neurasthenia  which  follows  them,  this  treatment  of  intervention  should 
be  conducted  in  two  stages  :  First  of  all,  the  reconstruction  of  the  former 
personality,  even  with  its  defects  and  moral  inferiorij;ies.  It  is  only 
much  later  that  one  will  have  the  right,  or  that  one  should  feel  it  to  be 
one's  duty,  to  attempt  to  eradicate  their  defects,  and  to  try  to  turn 
their  badly  directed  thoughts  into  new  directions.  This  springs  chiefly 
from  the  very  conception  which  we  have  given  of  sthenic  emotions  whose 
action  has  always  appeared  to  be  preponderant  in  psychotherapy  in  the 
moral  depths  of  the  neurasthenic.  Emotion,  which  we  try  to  use  thera- 
peutically, is  useful  only  in  so  far  as  it  acts  in  the  redirection  of  tihe 


302      THE  TREATMENT  OF  PSYCHONEUROSES. 

patient's  personality  itself.  One  can  understand  how  the  part  which 
the  physician  has  to  play  here  must  be  profoundly  humane.  It  is 
necessary  for  him  to  adapt  himself  wholly  to  the  mentality  of  his  pa- 
tient, and  to  be  filled  with  kindness,  pity,  and  indulgence,  so  that  he 
can  understand  the  most  subtle  sentimentalities,  and  sometimes  also  the 
most  flagrant  immorality.  His  function  is  to  be  always  that  of  the  con- 
soler, the  comforter,  the  giver  of  hope,  and  the  director  of  a  possible 
new  life.  In  order  that  his  work  may  have  any  result,  he  has  to  put  a 
great  deal  of  himself  into  it,  and  he  himself  must  feel  something  of  the 
emotion  which  he  is  seeking  to  bring  forth.  His  rôle  is  that  of  a  lay 
confessor,  or  a  moral  director,  judging  things  not  at  all  from  the  point 
of  view  of  life  itself.  He  must  understand  everything,  and  absolve 
everything.  He  must  know,  moreover,  that  in  the  great  majority  of 
cases  his  patients  are  people  who  are  too  grave,  and  who  err  through 
over-conscientiousness,  and  by  reason  of  their  excessive  scruples  and 
exalted  sentimentality.  Their  weaknesses  are  not  a  subject  for  satire 
or  irony  or  ridicule.  They  deserve  pity,  one  might  almost  say  respect. 
There  is  no  doubt  that  such  a  conception  of  the  function  of  the  physician 
is  peculiarly  remote  from  the  usual  methods  of  practice.  There  is  no 
doubt,  however, — although  it  is  so  very  simple,  and  demands  neither 
philosophic  conception  nor  strenuous  logic,  nor  even  any  very  great 
psychological  subtlety, — ^that  it  does  not  lie  in  the  power  of  all  those  who 
are  anxious  to  avail  themselves  of  the  value  of  the  moral  action  which 
they  wish  to  exercise. 

May  we  be  permitted  to  quote  a  few  lines  in  which  Bernardin  de 
St.  Pierre  has  defined,  more  exactly  and  better  perhaps  than  we  could 
do,  and  with  a  sort  of  prescience  of  what  is  needed,  the  very  rôle  that  we 
would  like  to  have  our  physicians  consent  to  play  to  our  patients  ? 

"I  wish  that  there  might  be  formed  in  large  cities  an  establishment, 
somewhat  resembling  those  which  charitable  physicians  and  wise  jurists 
have  formed  in  Paris,  to  remedy  the  evils  both  of  the  body  and  of  one 's 
fortunes;  I  mean  councils  for  consolation,  where  an  unfortunate,  sure 
of  his  secret  being  kept  and  even  of  his  incognito,  might  bring  up  the 
subject  of  his  troubles.  We  have,  it  is  true,  confessors  and  preachers  to 
whom  the  sublime  function  of  offering  consolation  to  the  unfortunate 
seems  to  be  reserved.  But  the  confessors  are  not  always  at  the  dis- 
position of  their  penitents.  As  for  the  preachers,  their  sermons  serve 
more  as  nourishment  for  souls  than  as  a  remedy,  for  they  do  not  preach 
against  boredom,  or  unhappiness,  or  scruples,  or  melancholy,  or  vexa- 
tion, or  ever  so  many  other  evils  which  affect  the  soul.  It  is  not  easy 
to  find  in  a  timid  and  depressed  personality  the  exact  point  about  which 
he  is  grieving,  and  to  pour  balm  into  his  wounds  with  the  hand  of  the 
Samaritan.  It  is  an  art  which  is  known  only  to  sensitive  and  sympathetic 
souls. 

**0h!  if  only  men  who  knew  the  science  of  grief  could  give  un- 


MORAL  AND  MENTAL  SUBSTRATUM.  303 

fortunate  people  the  benefit  of  their  experience  and  sympathy,  many  a 
miserable  soul  would  come  to  seek  from  them  the  consolation  which  they 
cannot  get  from  preachers,  or  all  the  books  of  philosophy  in  the  world. 
Often,  to  comfort  the  troubles  of  men  all  that  is  necessary  is  to  find 
out  from  w^hat  they  are  suffering."  (Bernardin  de  St.  Pierre,  ''Etude 
de  la  Nature,"  1784.) 

•  One  could  not  express  any  better,  or  any  more  directly,  what  we  never 
cease  to  maintain,  however  lacking  in  science  it  may  seem  at  the  first, 
— namely,  the  real  therapeutic  action  of  kindness. 

Liberated  morally,  and  having  regained  consciousness  of  self,  and 
freed  in  addition  from  his  functional  manifestations  by  the  appropriate 
processes  which  we  shall  study  further  on,  the  patient  is  cured.  He  is 
cured  from  his  actual  attack.  But  his  mental  foundation,  his  psycho- 
logical constitution,  still  remains  in  the  same  condition  which  permitted 
him  under  emotional  influences  to  become  a  neurasthenic.  The  rôle  of 
the  physician  is,  therefore,  not  ended.  He  must  still  build  up  his  pa- 
tient's life,  still  practise  prophylaxis,  and  get  the  patient  into  a  condition 
where  his  character  will  be  established.  He  has  the  right  to  exert  this 
action  not  only  upon  a  patient,  but  upon  any  subject  whose  moral  and 
mental  constitution  seems  to  indicate  a  predestination  to  a  neurasthénie 
psychoneurosis.  Furthermore,  it  seems  to  us  that  even  in  the  education 
of  a  child  there  is  a  place  for  peculiarly  prophylactic  moral  hygiene 
for  all  who  have  any  neuropathic  tendencies.  We  shall  devote  a  special 
chapter  to  this  study.  Here,  however,  the  therapy  would  be  quite 
different,  and  reason  and  explanations  would  become  preponderant. 

Is  there  such  a  thing  as  general  psychotherapy  for  hysteria,  as  there 
is  a  general  psychotherapy  for  neurasthenia? 

We  have  seen  in  a  preceding  chapter  (Part  II,  Chapter  XVII),  that 
the  hysterical  symptoms  were  much  more  closely  dependent  upon  the 
mental  constitution  than  upon  any  very  peculiar  moral  condition.  Un- 
doubtedly there  is  a  therapy  of  re-education  for  this  especial  moral  con- 
stitution, which  we  shall  glance  at  when  we  take  up  the  study  of  the 
general  prophylaxis  of  the  psychoneuroses. 

But,  independently  of  this  very  particular  rôle,  and  which  conceiois 
the  future  more  than  the  present,  the  immediate  therapeutic  action  still 
springs  from  psychotherapy.  We  have  mentioned  in  fact  the  action 
exercised  by  the  permanent  emotional  causes  on  its  production,  or  by 
the  mechanism  of  memory  and  evocation  on  the  persistence  of  hysterical 
symptoms.  Here  again,  the  liberating  action  of  confession  ought  to  be 
brought  into  play,  for  we  have  seen  a  great  number  of  hysterical  symp- 
toms which  had  hitherto  been  rebellious  give  in,  in  a  very  definite  way, 
when  the  subject  who  had  suffered  from  them  had  acknowledged  what 
their  origin  was.  This  fact  seems  to  us  to  be  of  great  doctrinal  impor- 
tance, for  it  shows  how  much  effect  the  synthesis  of  a  sthenic  emotion 


304      THE  TREATMENT  OF  PSYCHONEUEOSES. 

may  exercise  on  a  personality.  It  is  to  just  such  mechanisms  as  these 
that  one  must  attribute  the  therapeutic  influence  of  certain  places  to 
which  pilgrimages  are  made.  Sthenic  emotion  may  act  just  a^  well  upon 
a  mental  state  as  upon  a  moral  state,  just  as  a  depressing  emotion  exer- 
cises its  disintegrating  action  as  much  upon  the  moral  as  upon  the 
mental  state  of  the  subject  which  it  attacks. 

Therefore,  as  a  therapeutic  agent  its  efficacy  is  not  so  generally  evi- 
dent in  the  hysteric  as  in  the  neurasthenic,  but  must  not  for  that  reason 
be  neglected.  We  think,  therefore,  that  it  is  right  to  try  to  arouse  in  the 
hysteric  almost  the  same  sthenic  emotions  as  in  the  neurasthenic;  that 
it  is  wise,  as  with  the  neurasthenic  patient,  to  inquire  into  his  moral  con- 
dition, and  to  try  to  find  out  whether  his  personality  has  not  been  more 
or  less  completely  disorganized  by  the  emotional  stimuli  which  he  has 
undergone  and  which  his  memory  so  frequently  evokes.  In  the  great 
majority  of  cases,  such  inquiry  into  one's  moral  condition  and  the 
complete  liberation  by  confession  are  the  necessary  conditions — ^the  sine 
qua  non  of  the  cure  of  hysterical  symptoms. 

It  is  no  less  true  that  the  thing  which  at  a  given  time  dominates  the 
picture  of  hysteria  is  the  characteristic  symptom.  Some  peculiar  mental 
make-up  has  permitted  this  certain  symptom  to  be  produced,  and,  as 
the  therapy  of  the  patient's  mental  make-up  is  necessarily  connected 
with  that  of  the  symptom,  we  shall  continue  the  study  in  the  chapter 
devoted  to  the  treatment  of  hysterical  symptoms.  Let  us  say,  however, 
at  the  start,  for  this  is  a  point  to  which  we  shall  return  a  little  later, 
that  any  therapeutic  work  would  be  very  incomplete  if  it  confined  itself 
to  making  the  symptom  disappear,  or,  in  other  words,  to  treating  the 
symptom  without  paying  any  attention  to  the  mental  condition,  or  with- 
out offering  the  patient  any  refuge,  by  means  of  a  well-conducted  psycho- 
therapy, from  new  manifestations  of  his  affection.  This  purely  symp- 
tomatic therapy  is,  in  fact,  comparable  to  that  which  consists  in  treating 
a  syphilitic  headache  with  antipyrine  and  neglecting  to  treat  the 
syphilis. 


CHAPTER  XXII. 

A   GENERAL   PSYCHOTHERAPY   OF   FUNCTIONAL    MANIFESTATIONS. 

When  a  physician  has  to  deal  with  a  subject  afflicted  with  functional 
manifestations,  he  is  apt  to  think  that  he  has  an  easy  task  before  him. 
But  the  psychotherapeutic  procedure  which  consists  of  saying  to  the 
patient,  ''There  is  nothing  the  matter  with  you;  you  are  only  nervous; 
don't  pay  any  attention  to  it  .  .  ."  seems  to  us  a  little  too  simple,  and. 
above  all,  quite  inefficacious.  This,  however,  in  the  majority  of  cases 
is  practically  the  limit  of  most  physicians'  psychotherapy.  They  pay 
no  attention  either  to  the  mechanism  which  has  engendered  the  functional 
trouble  or  to  the  whole  series  of  symptomatic  phenomena  which  have 
come  in  to  complicate  the  situation.  If  the  mechanism  is  not  taken 
apart  bit  by  bit,  there  is  every  chance  that  it  will  be  built  up  again,  and 
will  bring  with  it  all  the  troubles  which  the  physician's  authoritative 
statement  has  been  for  the  moment'  able  to  disperse.  If,  on  the  other 
hand,  as  is  ordinarily  the  case,  the  additional  disturbances  exist  because 
of  the  patient's  incapability,  even  though  he  be  convinced  of  the  funda- 
mental neuropathic  nature  of  his  case,  of  completely  freeing  himself 
from  his  troubles,  the  symptomatic  ensemble  persists.  In  matters  of 
functional  manifestations  the  ''Know  thyself"  of  the  Socratic  doctrine 
is  exactly  the  thing  by  which  the  patient  realizes  his  maximum  chance 
of  a  definite  cure. 

The  first  thing,  therefore,  that  the  physician  has  to  do  is  to  interpret 
and  explain.  It  is  necessary  for  him  to  take  into  consideration  all  the 
constituent  elements  of  the  functional  manifestation.  If  there  is  any 
organic  tumor  or  growth,  it  will  be  wise  to  refer  to  its  existence  and  to 
show  the  patient  what  is  the  usual  symptomatology  ^hich  such  sub- 
jects present  who  are  affected  with  any  real  lesion;  by  a  sort  of  sub- 
traction, one  will  thus  finally  get  to  the  point  where  one  will  draw  out 
from  the  whole  array  of  symptoms  of  which  the  patient  is  complaining 
those  that  are  legitimate  and  those  that  are  not. 

To  our  way  of  thinking,  it  is  a  very  serious  error  to  undervalue  the 
rôle  played  in  certain  cases  by  the  organic  defect  ;  and  it  would  also  be 
a  great  mistake  to  try  to  deceive  the  patient,  when  there  is  any  such 
thing,  as  to  the  true  organic  difficulty  in  his  condition.  As  it  would  be  a 
material  impossibility  for  him  to  get  rid  of  all  his  symptoms,  there  would 
be  a  very  great  chance  that  he  would  not  get  rid  of  any  of  them. 

Outside  of  functional  manifestations  which  have  their  starting-point 

in  some  actual  organic  defect,  there  are  some  that  have  originated  from 

some  passing  organic  phenomenon.     It  is  necessary  to  take  these  into 

consideration  also,  and  to  explain  to  the  patient  that  originally  his 

20  305 


306      THE  TREATMENT  OF  PSYCHONEUROSES. 

symptoms  sprang  from  some  real  trouble.  This  is  because  it  often 
happens  that  certain  functional  manifestations  bear  a  relation  to  some 
definite  or  transient  organic  defect,  antecedent  even  to  the  neurasthenic 
condition.  The  patient  who  knows  what  the  succession  of  phenomena 
has  been  in  his  own  case  will  find  it  very  difficult  to  admit,  without  any* 
preliminary  explanation,  that  what  he  is  feeling  now  is  purely  neuro- 
pathic, and  when  one  tries  to  prove  too  much  to  him  one  will  prove 
nothing  at  all. 

Finally,  there  exists  with  the  major  neurasthenic  a  whole  series  of 
manifestations  of  which  some  have  to  do  with  emotional  fatigue  and 
others  are  related  to  later  organic  weaknesses.  It  is  right  for  the 
physician  to  explain  to  his  subject  not  only  the  neuropathic  origin  of 
his  symptoms,  but  also  the  real  nature  of  the  troubles  of  which  he 
complains.  What  he  must  then  point  out  to  the  patient  is  the  direct 
curability  of  his  troubles,  and  what  he  must  avoid,  while  of  course  mak- 
ing reservations  concerning  the  exaggeration  and  prolongation  of  mental 
origin,  is  telling  the  patient  of  the  purely  psychic  nature  of  these 
difficulties. 

There  is,  therefore,  a  whole  series  of  therapeutic  shoals  on  which 
the  physician  may  be  shipwrecked  if  he  trusts  to  any  too  decided 
systematization,  but  which  with  a  little  tact  and  good  sense  it  is  quite 
possible  for  him  to  avoid. 

However,  it  is  not  only  real  phenomena  which  must  be  taken  into 
consideration.  One  must  pay  the  greatest  attention  to  what  we  have 
already  elsewhere  called  disharmonie  disturbances.  Here  is  an  organ 
or  a  function  which  for  weeks,  months,  or  even  sometimes  years,  under 
the  influence  of  neuropathic  disturbances  has  been  mobilized  in  some 
vicious  attitude,  or  whose  functioning  has  been  quite  abnormal.  It  is 
clear  that  phenomena  arise  which  are  the  direct  result  of  the  bad  habits 
that  are  formed  and  that  they  must  not  be  associated  with  purely  psychic 
manifestations.  Moreover,  a  peculiar  therapy  must  be  applied  to  these 
latter  phenomena.  This  therapy  is  called  re-education,  a  method  which, 
by  various  and  different  processes,  according  to  the  functional  mani- 
festation in  question,  progressively  corrects  the  vicious  attitude,  and 
frees  or  releases  the  patient  from  the  bad  habit  which  he  has  formed. 
For  every  organ  and  every  function  that  is  affected  in  this  way  there 
is  some  particular  form  of  re-education.  But,  speaking  in  a  general 
way,  explanations  form  a  very  considerable  part  of  it,  for  one  must 
show  the  patient  how  and  in  what  way  he  has  sinned,  and  what  is  the 
exact  rôle  which  in  the  general  group  of  phenomena  experienced  by  him 
is  played  by  disharmonie  disturbances. 

All  these  eliminations  being  made,  we  get  to  what  is  properly  called 
the  psychic  part.  This,  unquestionably,  is  very  important.  But  the 
most  dangerous  error,  also  the  most  frequent,  is  that  of  confounding 
the  psychic  manifestation  with  the  imaginary  manifestation.    The  hypo- 


FUNCTIONAL  MANIFESTATIONS:  PSYCHOTHERAPY.  307 

chondriac  is  the  only  one  who  has  imaginary  manifestations  which  are 
the  pure  fabrications  of  his  mind,  although  sometimes  due  to  medical 
questioning.  The  symptoms  of  a  neurasthenic  are  legitimate  sufferings, 
quite  as  legitimate  as  if  they  were  due  to  some  affected  organ;  only, 
instead  of  having  had  a  peripherical  origin,  they  have  had  a  central 
starting-point, — that  is,  a  psychic  starting-point.  It  is  quite  under- 
stood that  the  neurasthenic  is  apt  to  exaggerate  his  sufferings,  and  one 
must  always  remember  this  fact,  which  is  true  even  for  patients  who 
are  organically  afflicted,  that  the  pain  which  is  a  purely  subjective 
phenomenon  is  felt  in  proportion  to  the  attention  that  is  brought  to 
bear  upon  it.  But  to  tell  a  neurasthenic  that  what  he  feels  is  ''merely 
an  idea"  shows  a  very  poor  comprehension  of  the  exact  mechanisms  of 
the  troubles  from  which  he  is  suffering.  It  is,  therefore,  very  wise  to 
make  the  patient  grasp  the  fact  that  psychic  phenomena  and  organic 
phenomena  are  by  no  means  independent  of  one  another,  but  that  their 
reciprocal  action  is  felt  in  a  double  sense,  either  by  an  organic  trouble 
created  by  a  psychic  impression,  or  else,  w^hich  is  true  in  this  particular 
case,  that  a  previous  psychic  impression  may  disturb  an  organic  function. 
The  functional  disturbance  of  psychic  origin  thus  realized  is  itself  sus- 
ceptible of  having  a  psychic  expression,  and  of  strengthening  the 
pathological  convictions  for  the  patient,  which  in  their  turn  become 
factors  of  a  still  more  marked  disturbance.  Thus  is  formed  the  vicious 
circle  into  which  psychotherapy  must  penetrate.  The  patient,  from  the 
moment  that  he  finds  that  you  are  not  going  to  treat  him  like  an  invalid 
who  is  making  believe,  is  quite  disposed  to  admit  the  very  reassuring 
mechanism  which  you  explain  to  him.  It  will  be  proper  thenceforward 
to  show  him  just  what  is  the  exact  and  precise  origin  of  his  auto-  or 
hetero-suggestions,  and  what  is  the  influence  which  emotional  causes 
exert  upon  him.  It  will  be  necessary  to  demonstrate  to  him  the  rôle 
played  by  all  associations  of  ideas,  and  memories  which  bound  by  ties 
of  succession  or  causality  to  the  pathological  idea  are  apt  to  recall  it  and 
with  it  all  the  disturbances  which  depend  upon  it.  In  this  way  you  will 
be  able  to  explain  to  him  the  apparent  regularity  of  certain  manifesta- 
tions which  always  spring  up  at  a  given  moment,  because  following  the 
ordinary  psychological  mechanism,  which  one  can  easily  understand,  it 
is  at  the  very  moment  that  the  psychism  of  the  patient  finds  itself 
directed  toward  the  manifestation  which  it  presents. 

The  rôle  of  association  of  ideas  and  the  awakening  of  the  patho- 
logical idea  through  memory  has  always  seemed  to  us  of  very  great 
importance.  It  is  in  this  way  we  feel  that  a  great  number  of  functional 
manifestations  are  prolonged  and  complicated  and  exaggerated.  It  is 
also  by  reason  of  not  taking  this  fact  into  account  that  so  many  thera- 
peutic procedures  based  on  the  re-education  of  a  will,  which  moreover 
is  often  by  no  means  deficient,  only  leads  to  very  uncertain  results.  The 
essential  thing  for  a  neurasthenic  is,  first  of  all,  not  to  struggle,  but 


308      THE  TREATMENT  OF  PSYCHONEUROSES. 

rather  to  make  himself  forget,  and,  when  one  advises  that  certain 
patients  should  be  isolated  for  a  time,  it  is  precisely  in  order  to  reduce 
to  the  minimum  the  chances  for  recalling  the  pathological  idea.  This 
recall  is  produced  during  the  course  of  the  treatment  by  the  intervention 
of  psychological  associations,  of  which  the  objects  and  familiar  things 
of  the  environment  in  which  the  patient  has  lived  constitute  one  element 
while  the  functional  manifestation  forms  the  other.  If  later  one  ad- 
vises the  patient  who  has  grown  strong  and  understands  his  case,  to 
struggle  against  a  new  attack,  and  against  all  memories  which  tend  to 
invade  his  mind  again,  nothing  can  be  better.  But  at  the  beginning  of 
the  treatment,  as  far  as  the  functional  manifestation  is  concerned — 
except,  however,  where  in  certain  cases  there  is  more  precise  indication 
— ^the  thing  that  one  must  pay  particular  attention  to  is  to  preserve 
silence,  at  least  in  the  psychological  recesses  of  the  patient's  mind. 

One  only  forgets — ^one  can  only  forget — the  things  which  no  longer 
preoccupy  and  disturb  one.  To  know  one's  enemy  is  already  to  be  in  a 
position  where  one  does  not  fear  him.  To  fear  him  no  longer  prac- 
tically means  the  same  thing  as  to  neglect  him.  The  whole  treatment 
of  functional  troubles,  outside  of  some  particular  cases,  lies  in  so  dis- 
posing the  patient's  mind  that  he  has  a  feeling  of  intelligent  security 
in  regard  to  the  symptoms  with  which  he  is  attacked. 

A  patient  will  only  feel  himself  cured  when  in  all  good  faith  he  can 
say  to  you,  when  speaking  of  his  troubles,  '  '  I  never  think  of  them  now.  '  ' 

Under  some  circumstances,  and  in  the  presence  of  convictions  which 
are  too  deeply  rooted  in  the  patient,  one  might  be  led  to  penetrate  his 
systematization  by  taking  him  by  surprise.  The  principle  of  this  process 
consists  in  making  the  subject  do,  without  his  having  paid  any  attention 
to  it,  some  particular  act  which  he  believed  himself  incapable  of  accom- 
plishing, or,  again,  by  warding  off,  by  some  happy  intervention,  the 
usual  returns  of  the  pathological  phenomenon.  The  employment  of 
such  proceedings  naturally  necessitates  a  certain  ingenuity  on  the  part 
of  the  physician,  for  it  is  very  important  that  he  should  succeed.  He 
will  run  the  risk,  in  case  of  failure,  of  increasing  the  disturbances 
against  which  he  is  struggling. 

When  it  has  happened,  for  example,  that  he  has  been  able  to  get 
an  asthenic  individual  to  take  a  little  walk  with  him,  or  when  he  has 
been  able  by  keeping  up  the  conversation  to  go  past  the  given  hour  at 
which  such  or  such  a  gastric  trouble  is  due  to  appear,  he  must  take  care 
not  to  be  in  too  great  a  hurry  to  show  his  triumph.  The  patient  will 
immediately  seek  excuses  for  his  lapse  from  his  functional  troubles,  and 
there  is  a  very  great  chance  that  on  the  next  day  he  will  come  back 
to  you  completely  upset,  or  more  dyspeptic  than  ever.  ** Doctor,"  he 
vnll  say  to  you,  '*you  let  me  do  a  very  imprudent  thing,"  or  else,  '*I 
began  to  feel  a  pain  in  my  stomach  when  I  went  away  from  your  house, 
and  it  has  never  left  me  the  whole  day."    Keep  your  triumph,  then, 


FUNCTIONAL  MANIFESTATIONS:  PSYCHOTHERAPY.  309 

for  a  time  at  least,  a  secret,  and  if,  on  the  next  day  and  the  day  after, 
nothing  new  has  happened,  then — and  then  only — show  your  patient 
the  illogical  character  of  troubles  which  may  be  made  to  disappear  by 
distraction. 

But  do  not  be  deceived.  This  *' trick,"  if  one  might  use  that  ex- 
pression, is  only  very  rarely  necessary  and  is  not  always  without  danger. 
One  can  hardly  employ  it  systematically  without  regret.  There  are  a 
great  many  very  precise  indications  which  it  will  run  up  against,  as 
we  shall  see  further  on  in  the  peculiar  manifestations  of  sexual  dis- 
turbances. 

Does  this  mean  that  in  the  treatment  of  functional  manifestations 
the  emotional  elements,  whose  action  we  have  seen  to  be  preponderant 
in  psychotherapy  on  the  moral  condition  of  the  neurasthenic,  have  com- 
pletely lost  their  sway?  By  no  means.  In  the  first  place,  no  explana- 
tion whatever  will  be  accepted  by  the  patient  until  he  has  confidence  in 
his  physician,  but,  even  if  the  patient's  reason  may  progressively  re- 
spond to  convincing  arguments,  it  may  happen  that  his  feelings  do  not 
keep  up  with  the  march.  He  will  be  quite  aware  that  he  is  unreason- 
able, and  that  he  is  behaving  in  such  or  such  a  manner  ;  but  he  would 
much  rather  be  considered  unreasonable  than  to  change  his  ways,  if 
the  emotional  elements,  which  at  bottom  are  the  only  ones  with  any 
determining  power,  do  not  come  into  play.  He  may  know  that  he  is 
wrong  in  suffering,  but  he  will  continue  to  suffer,  and  that  will  not 
change  his  situation  in  the  slightest.  If,  on  the  other  hand,  you  have, 
to  use  a  slang  expression,  *'got  him,"  if  he  feels  perfect  confidence  in 
his  physician,  he  will  feel  perfect  faith  that  his  symptoms  will  by  and 
by  disappear,  and  then  you  can  get  him  to  do  almost  anything  that 
you  want.  Anything  that  you  wish  him  to  do  or  any  effort  necessary 
to  break  up  the  vicious  circle  connected  with  all  his  functional  troubles 
he  will  do,  even  though  he  may  for  the  time  being  suffer  considerably. 
His  cure  will  then  take  place  rapidly,  because  not  only  will  he  have 
taken  a  new  direction  through  his  reason  but  will  be  urged  along  in  it 
by  his  feelings. 

As  a  matter  of  fact,  in  the  therapy  of  functional  manifestations, 
the  physician  has  not  only  to  struggle  against  pathological  convictions 
and  against  errors  of  interpretation,  but  he  has  also  to  combat  appre- 
hensions. The  latter  naturally  result  from  the  former.  But  when 
functional  manifestations  have  been  prolonged  for  a  sufficient  length 
of  time  the  apprehension  becomes  involuntary  and  subconscious,  and 
tends  to  persist  even  when  in  the  mind  or  the  pure  reason  of  the  pa- 
tient the  convictions  have  been  destroyed  and  the  errors  repaired.  And 
it  is  only  under  the  influence  of  the  action  of  sthenic  emotions  that  the 
patient  can  get  control  of  his  apprehensions  and  manage,  after  a  greater 
or  less  length  of  time,  to  forget  them. 

The  treatment  of  functional  manifestations  demands  more  explana- 


310      THE  TREATMENT  OF  PSYCHONEUROSES. 

tions  and  more  reasoning  than  the  treatment  of  the  moral  depths  of 
the  neurasthenic.  But  in  one  case  as  well  as  in  the  other  we  cannot 
say  too  often  that  there  is  no  such  thing  as  cold-blooded  psychotherapy. 

And  if  this  is  true  for  the  treatment  of  the  functional  manifestation 
considered  in  itself,  it  is  still  more  true  if  one  considers  the  mental 
depths  themselves  which  have  permitted  these  manifestations  to  be- 
come established  and  which  contribute  to  make  them  persistent.  The 
general  conviction  of  helplessness,  the  habit  of  auto-analysis  and  auto- 
observation,  the  search  for  the  symptom  and  its  magnification, — elements 
which  are,  moreover,  rather  of  the  moral  than  of  the  psychic  order, — 
have  participated  in  the  genesis  of  all  the  symptoms  which  the  neuras- 
thenic offers.  It  is  very  certain  that,  by  explanation  and  reasoning 
which  permits  the  patient  to  become  reassured  concerning  the  origin  of 
all  his  troubles,  all  these  psychological  phenomena  will  have  a  great 
chance  of  becoming  diminished. 

But  there  will,  nevertheless,  always  be  something  left  behind, — a 
sensation  of  vague  insecurity,  a  feeling  of  anxiety  about  the  return  of 
the  troubles  which  have  disappeared.  This  is  something  which  can  only 
be  completely  abolished  under  the  influence  of  strong  emotional  growth. 
This  is  the  same  thing  as  saying  that  one  cannot  treat  a  functional 
trouble  alone,  even  by  the  most  persuasive  or  the  most  incisive  psycho- 
therapy, without  at  the  same  time  being  concerned  with  the  general 
moral  condition  of  the  patient  and  without  trying  to  modify  it,  and 
that  only  can  be  brought  about  through  feeling  and  sympathy. 


CHAPTER  XXIII. 


THE  ADJUVANTS  OP  PSYCHOTHERAPY. 


Before  taking  up  the  study  of  the  detailed  treatment  of  the 
functional  manifestations,  it  seems  to  us  advisable  to  glance  at  the 
rôle  which  certain  therapeutic  agents,  such  as  isolation,  rest,  and  over- 
feeding, play  in  the  treatment,  and  state  a  little  more  definitely  just 
when  they  are  indicated,  for  one  will  often  have  occasion  to  utilize  them, 
and  under  certain  circumstances  they  are  necessary  adjuncts  of  the 
psychotherapy  of  persuasion. 

There  wa^  a  time  when,  associated  with  rest  and  overfeeding,  isola- 
tion formed  the  basis  of  all  therapy  connected  with  the  psychoneuroses. 
According  to  our  way  of  thinking,  isolation,  even  accompanied  by  rest 
and  overfeeding,  is  never  enough.  Neither  is  it  any  more  considered 
to  be  always  absolutely  necessary.  Just  as  there  can  be  no  such  thing 
as  any  "sure  cure"  for  the  psychoneuroses,  so  it  would  be  irrational 
to  look  upon  the  isolation  of  neuropaths  as  a  therapeutic  necessity  from 
which  one  might  never  depart.  It  only  applies  to  particular  cases  and 
is  subjected  to  a  few  general  rules. 

But,  first  of  all,  what  must  one  understand  by  isolatio'nf  The 
usual  thing  is  to  consider  isolation  as,  first  and  foremost,  consisting  of 
the  almost  absolute  seclusion  of  the  patient,  which  can  only  be  accom- 
plished in  a  sanitarium  or  a  hospital.  A  patient  is  shut  up  in  a  room, 
into  which  no  one  but  the  physician  and  the  nurse  may  enter.  He 
receives  no  letters,  is  allowed  no  visitors,  and  is  permitted  no  relations 
with  anybody  except  those  people  who  are  in  care  of  his  treatment. 

One  step  further  in  isolation,  which  is  really  rather  one  step  further 
in  the  rest  treatment,  may  be  obtained  when  one  keeps  the  patientas 
room  in  a  state  of  semi-darkness,  and  when  one  does  not  allow  him  to 
have  the  slightest  knowledge  outside  of  the  very  narrow  environment 
in  which  he  finds  himself. 

One  degree  less  consists  of  permitting  the  patient,  although  he  may 
not  take  any  part  in  it,  to  know  what  is  going  on  outside,  and  to  watch 
and  be  interested  in  the  life  around  him.  This  is  already  the  beginning 
of  outside  interests  for  the  patient. 

Provided  that  one  approaches  this  by  regular  gradations,  or,  on  the 
contrary,  that  one  is  satisfied  that  it  can  be  introduced  at  the  start,  one 
may  go  quite  far  in  this  method  of  modified  isolation,  even  so  much  so 
as  simply  to  ask  the  patient  to  withdraw  from  his  daily  duties  and  his 
customary  surroundings. 

This  is  because,  as  a  matter  of  fact,  isolation  is  not  a  simple  thera- 
peutic agent.    It  is  not  an  end;  it  is  only  a  means  which  is  absolutely 

311 


312      THE  TREATMENT  OF  PSYCHONEUROSES. 

necessary  in  a  great  number  of  cases,  in  order  to  be  able  to  apply 
psychotherapy  with  success. 

Reasons  of  an  extremely  varied  nature,  which  sometimes  are  com- 
pletely foreign  to  the  patient  considered  by  himself,  may  make  it 
necessary. 

Here,  for  example,  is  a  subject  who  has  a  very  bad  family  environ- 
ment, and  who  has  often  found  the  cause  of  his  neurasthenia  in  this 
environment  itself.  There,  on  the  other  hand,  is  a  family  who  treats  a 
neurasthenic  like  a  make-believe  invalid,  and  who  consequently  ex- 
aggerates the  sufferings  of  a  poor  wretch,  who  often  ''wants  to  do 
things,  but  really  cannot,"  or  else,  on  the  other  hand, — and  this  is 
more  apt  to  be  the  case, — it  is  a  family  who  by  its  too  fussy  care  and 
perpetual  anxiety  encourages  the  patient  in  his  depressing  ideas  and  in 
his  unhealthy  point  of  view.  Thus,  we  see  that  the  psychotherapeutist 
has  many  reasons  which  point  out  very  definitely  the  need  of  isolation 
from  one's  environment. 

Let  us  take  the  mother  of  a  family  who  although  neurasthenic  still 
keeps  up  her  pride  in  the  appearance  of  her  home.  Just  as  long  as 
she  lives  there  she  cannot  help  but  play  the  part  of  wife,  and  attend 
to  her  duties  as  mistress  of  her  home.  The  education  and  the  health 
of  her  children  are  continually  on  her  mind.  What  really  serious 
psychotherapeutic  action  could  one  practise  upon  her  under  these  con- 
ditions? It  is  very  evident  that  there  will  always  be  a  continual 
tendency  for  her  thoughts  to  turn  toward  her  home  and  her  loved  ones. 
Here  isolation  and  separation  from  her  environment  are  absolutely  in- 
dicated. It  would  not  be  the  gravity  of  the  patient's  condition  that 
would  be  the  principal  reason  for  her  isolation. 

Let  us  suppose,  on  the  other  hand,  that  a  subject  who  has  been 
neurasthenic  for  some  years,  and  more  or  less  phobic,  and  afflicted  with 
numerous  functional  manifestations,  has  always  lived  in  one  spot.  Can- 
not one  understand  that  under  these  conditions  his  sickness,  as  it  were, 
hangs  on  the  very  walls  which  surround  him?  Each  piece  of  furniture 
and  every  little  object  under  his  hand  has  been,  as  a  matter  of  fact, 
associated  with  some  distressing  moment  of  his  life.  It  is  perfectly 
clear  that,  by  the  common  mechanism  of  the  association  of  ideas,  his 
surroundings  will  continually  recall  to  the  patient  his  sickness  and  all 
his  symptoms.  Go,  under  these  conditions,  and  tell  him  to  forget,  for 
that  is  the  last  word  of  psychotherapy  concerning  functional  manifesta- 
tions, as  we  shall  see  later  on.  Here,  again,  you  will  see  that  isolation,, 
which  means  isolation  from  his  environment,  is  obligatory. 

Take  an  individual  who  has  become  neurasthenic  because  he  has  lost 
one  of  his  family,  a  wife  or  a  child.  Cannot  one  see  that,  if  he  remains 
in  the  same  environment  in  which  he  experienced  these  sorrows,  the 
emotional  cause  will  have  every  chance  of  prolonging  its  disintegrating 
action  in  a  way  that  will  be  almost  indefinite  ?    Until  he  has  completely 


THE  ADJUVANTS  OF  PSYCHOTHERAPY.      3ia 

gotten  hold  of  himself  the  patient  ought  to  be  wholly  separated  from 
his  former  environment. 

Here  is  an  hysterical  patient  who  is  subject  to  attacks  of  paralysis, 
and  contracture.  How  can  one  hope  for  any  improvement  in  his  symp- 
toms if  he  is  left  with  his  family? 

Here,  again,  is  a  case  of  mental  anorexia,  showing  the  results  of 
excessive  lack  of  nutrition.  How  can  one  obtain  any  favorable  result 
if  the  patient  remain  in  the  family  circle?  Here,  as  in  the  preceding 
case,  absolute  isolation  is  necessary. 

In  all  these  cases  isolation  from  one*s  environment  and  from  one's 
daily  routine  is  the  underlying  condition  of  psychotherapeutic  treat- 
ment, whose  action  otherwise  would  be  rendered  completely  useless. 

There  are,  on  the  other  hand,  subjects  who  are  in  the  very  midst  of 
some  moral  upheaval,  in  a  condition  that  one  might  describe  as  extreme 
emotional  hypertension.  The  slightest  thing  depresses  them;  they  are 
extremely  irritable.  Here  isolation  is  indicated,  and  not  merely  isola- 
tion from  one's  family  circle  and  from  one's  daily  surroundings,  but, 
still  further,  complete  isolation  which  shall  be  almost  absolutely  free 
from  any  external  excitation.  With  such  subjects  we  enter  upon  a 
series  of  cases  where  isolation  is  not  merely  a  condition  of  psycho- 
therapy, but  where  it  becomes  the  condition  of  absolute  rest,  which  is 
necessary  for  certain  patients.  Such  is  the  case,  for  example,  with 
people  who  suffer  from  extreme  exhaustion.  The  statement  of  this 
formula,  that  complete  rest  can  only  be  obtained  in  isolation,  gives  ua 
the  key  to  all  the  cases  where  strict  isolation  is  indicated. 

This  same  strict  isolation  may  be  utilized  under  certain  circum- 
stances as  a  true  psychotherapeutic  measure.  Certain  subjects  with  a 
weak  will,  many  hysterics,  and  children,  as  a  general  rule,  in  order 
to  be  freed  from  an  isolation  which  weighs  heavily  upon  them,  will  find 
themselves  capable  of  getting  their  ideas  to  work,  a  thing  which  could 
not  have  been  accomplished  otherwise  without  great  difficulty.  But, 
they  will  tell  us,  in  this  cloistral  isolation  the  patients  will  be  apt  to 
become  very  uneasy  and  disturbed  concerning  the  health  of  their 
families.  How  can  one  deprive  a  mother  of  a  family  of  news  of  her 
children?  Your  subjects'  minds  cannot  be  at  rest  and  in  a  tranquil 
state,  and  therefore  they  will  be  in  very  poor  condition  to  get  well. 
If  things  happen  in  this  way  the  objection  would  be  wisely  taken,  but 
this  is  not  the  case.  Every  subject  who  is  obliged  to  go  into  strict 
isolation,  and  who  is  consequently  deprived  of  letters  and  of  visits,  will 
ifeceive  every  day  absolutely  exact  news  of  what  has  happened  in  his 
family.  Furthermore,  he  knows,  for  he  is  told  at  the  start,  that  if 
one  of  his  family  should  fall  sick  he  would  be  immediately  told  of 
the  fact,  and  would  be  allowed  to  interrupt  his  treatment  and  go  home. 
This  is  the  only  way  in  which  strict  isolation  can  be  undertaken  with- 


314     THE  TREATMENT  OF  PSYCHONEUROSES. 

out  disturbing  the  moral  tranquillity  of  those  who  are  obliged  to  submit 
to  it. 

We  only  insist  on  isolation  either  in  a  sanitarium  or  in  a  hospital 
because,  by  reason  of  the  great  number  of  patients  being  brought  to- 
gether in  different  periods  of  their  disease,  there  is  necessity  for  a 
special  discipline.^ 

Let  us  say,  however,  that  each  time  that  strict  isolation  is  indicated, 
it  can  only  be  practised  at  a  hospital  or  a  sanitarium,  because  there, 
and  there  only,  the  patients  will  find  the  proper  personal  attendance 
adapted  to  the  various  cares  which  their  condition  demands.  In  short, 
in  order  to  have  the  psychotherapeutic  action  which  the  physician  lays 
out  practised  continually,  it  is  of  great  importance  that  it  should  not 
be  interrupted  by  maladroit  interventions  of  some  second  person.'  By 
breaking  the  disciplinary  rules  of  strict  isolation,  by  ill-chosen  conversa- 
tions, or  simply  by  those  that  last  too  long,  the  nurse  or  attendant  may 
be  as  dangerous  to  the  neuropathic  patient  as  he  would  be  if  he  handed 
around  iced  drinks  to  pneumonia  patients  or  if  he  gave  a  typhoid 
patient  all  that  he  wanted  to  eat.  The  choice  of  the  persons  who  assist 
the  physician  is,  therefore,  of  very  great  importance. 

To  sum  up,  we  would  say  that  isolation  may  be  prescribed  in  three 
different  degrees, — namely: 

(1)  Strict  isolation. 

(2)  Absolute  isolation  from  one's  family  circle  and  environment. 

(3)  Isolation  from  one's  family  circle  alone,  or  from  one's  en- 
vironment alone.  In  this  latter  case  one  either  takes  the  patient  away 
from  his  home  but  allows  one  of  his  family  to  accompany  him,  or  else 
lets  him  stay  in  his  home  but  separates  him  from  the  people  who 
usually  surround  him. 

It  is  evident  that  the  third  degree  differs  only  quantitatively  from 
the  second,  as,  as  a  matter  of  fact,  one's  environment  forms  a  con- 
stituent part  of  one's  circle,  and  that  there  are  particular  cases  which, 
according  to  the  causes  which  have  brought  about  the  patient's  con- 
dition and  the  symptoms  which  he  shows,  and  also  according  to  the 
positive  or  negative  therapeutic  value  of  his  surroundings,  indicate 
that  there  is  a  necessity  of  absolute  isolation  from  one's  family  circle 
and  from  one's  environment,  or  from  only  one  of  these  two  elements. 

Cloistral  isolation  cannot  be  realized  except  at  a  sanitarium  or  at  a 
hospital.  This  is  because  the  hospital  or  sanitarium  offers  the  best 
opportunity  of  isolation  of  the  second  degree.  One  could  also  under 
certain  circumstances  send  a  patient  to  a  hydrotherapeutic  or  thermal 
establishment,  or  to  stay  in  the  country,  anywhere,  in  fact — ^but  this  is 
the   imperative   condition — where   he   could   find   proper  psychothera- 

*One  will  find  in  the  work  of  Camus  et  Pagniez,  I.e.,  very  complete  details 
concerning  the  organization  of  hospital  isolation  such  as  has  been  practised  by  one 
of  us  for  fifteen  years  during  his  service  in  the  Pinel  Ward  at  the  Salpêtrière. 


THE  ADJUVANTS  OF  PSYCHOTHERAPY.      315 

peutic  treatment.  Isolation  from  one's  family  alone  can  also  be  accom- 
plished under  the  same  conditions  by  permitting  a  patient  to  be 
accompanied  by  one  of  the  members  of  his  family. 

As  to  isolation  from  one's  social  environment,  it  does  not  have  to 
take  place  so  very  often,  and  it  is  rendered  necessary  for  very  special 
reasons.  As  a  general  rule,  it  will  be  much  simpler  to  separate  the 
patient  from  both  his  environment  and  his  family  circle  at  the  same 
time  by  proceeding  as  we  have  just  indicated. 

The  reader  may  ask  whether  it  is  possible  for  us  to  indicate  ap- 
proximately, among  patients  afflicted  with  a  great  variety  of  neuro- 
pathic symptoms,  what  is  the  proportion  of  those  for  whom  isolation, 
in  its  various  degrees,  is  necessary?  Here  it  is  evidently  a  question  of 
kinds.  Nevertheless,  in  order  to  get  some  idea  of  it  and  to  show  how 
slightly  our  experience  has  inclined  us  toward  any  systematic  treatment 
of  the  psychoneuroses  by  isolation,  we  might  say  that  for  at  least  a 
third  of  the  neuropathic  women  who  have  been  cared  for  at  the 
Salpêtrière  isolation  has  not  seemed  to  us  to  be  necessarj^  Again,  it 
must  be  added,  that,  of  the  patients  admitted,  a  certain  number  have 
been  received  at  the  hospital  and  naturally  submitted  to  the  discipline 
which  belongs  to  an  isolation  ward  much  more  for  humanitarian  and 
social  reasons  than  because  absolute  isolation  seemed  to  be  formally 
indicated. 

Rest,  like  isolation,  is  not  such  a  simple  idea  but  that  it  would  be 
useful  to  analyze  it.  It  seems  to  be  the  simplest  thing  in  the  world  to 
advise  a  patient  to  take  a  rest.  As  a  matter  of  fact,  there  are  very 
few  therapeutic  agents  which  are  as  badly  handled  as  that.  Rest  im- 
plies elements  of  various  kinds.  There  is  physical  rest,  and  psychic 
rest,  and  moral  rest,  which  are  not  necessarily  associated. 

Let  us  glance  first  of  all  at  physical  rest.  Its  maximum  is  evidently 
realized  by  keeping  the  patient  in  bed  altogether  for  a  considerable 
time.  Under  certain  circumstances  it  may  be  necessary  to  impose  it 
absolutely,  but  it  is  chiefly  indicated  because  outside  of  absolute  rest 
it  is  extremely  difficult  to  attain  any  definite  amount  of  comparative 
rest.  It  would  seem,  on  first  looking  at  it,  that  one  might  grade  the 
rest  by  ordering  patients  to  remain  in  bed  for  twelve,  fourteen,  eighteen, 
or  twenty  hours  ;  but  the  thing  that  must  be  considered  then  is,  not  the 
time  which  the  patient  passes  in  bed  or  lying  down,  but  the  use  that  he 
makes  of  the  moments  when  he  is  permitted  to  move  about.  Here,  for 
example,  is  an  asthenic,  convinced  of  his  physical  helplessness,  who 
when  walking  makes  all  kinds  of  movements  which  are  disharmonie, 
and  who  in  a  few  moments  really  tires  himself  out  as  much  as  a  normal 
man  would  tire  in  ten  or  twenty  times  the  length  of  time.  Of  what  use 
is  it  to  prescribe  for  him  any  very  long  period  of  rest  if  in  the  interval 
between  he  loses  all  the  benefit  of  it?  On  the  other  hand,  one  sees 
patients  who  are  always  moving  about  in  bed,  who  are  restless  and 


316      THE  TREATMENT  OF  PSYCHONEUROSES. 

continually  changing  their  position  or  altering  the  arrangement  of  their 
covers,  who  change  the  position  of  their  pillow  a  hundred  times.  Where 
in  such  cases  does  the  physical  rest  which  you  want  to  get  for  them 
come  in? 

Another  one  will  lie  perfectly  still  in  his  bed,  but  he  will  hold  him- 
self in  a  wrong  position  which  after  a  short  time  will  bring  about  a 
feeling  of  numbness  in  one  of  his  limbs,  or  congestion  of  the  head,  or 
cold  in  the  feet,  from  all  of  which  symptoms  he  will  suffer  distress  and 
become  exasperated,  and  which  by  a  different  mechanism  will  make  him 
lose  the  benefit  of  his  rest. 

All  of  which  means  that  to  put  a  patient  through  a  course  of  treat- 
ment requiring  absolute  or  comparative  rest  is  not  only  to  command 
him  to  lie  physically  still  for  a  certain  number  of  hours,  but  it  also 
means  to  lay  down  a  course  of  discipline  for  the  intervals  of  rest,  and 
to  assure  those  very  conditions  under  which  the  rest  will  be  realized. 
In  the  case  of  absolute  rest,  how  much  time  will  it  be  necessary  to  keep 
the  patient  continually  in  bed?  Here,  again,  it  is  a  question  of 
particular  cases.  Among  those  who  are  very  much  exhausted,  or 
very  much  emaciated,  and,  above  all,  in  those  where  absolute 
rest  is  indicated,  complete  confinement  to  one^s  bed  may  vary 
from  several  weeks  to  several  months.  In  a  general  way  we  estimate 
that  the  physician  must  be  guided  chiefly  by  the  patient's  increase  in 
weight.  The  faster  he  gains  weight  the  shorter  will  be  the  time  that 
he  has  to  stay  in  bed,  and  by  degrees  he  can  be  brought  back  to  the 
times  and  seasons  of  normal  life. 

Now  to  pass  on  to  the  question  of  mental  rest.  The  formula  con- 
sists in  prohibiting  all  brain  work  for  the  patient.  Our  subject  must 
give  up  all  his  business  occupations,  leave  his  office,  get  away  from  his 
library.  He  will  not  improve  any  more  quickly  for  that,  but  rather 
otherwise,  if  he  continues  to  think  about  things,  and  if  a  thousand 
ideas  surge  through  his  agitated  brain.  It  is  necessary,  therefore,  for 
the  prescription  of  mental  rest  to  be  accompanied  by  a  certain  number 
of  points  to  be  observed.  We  are  in  the  habit  of  telling  a  great  many 
of  our  patients  to  try  to  put  themselves  all  the  time  into  the  condition 
of  the  subject  who  is  trying  to  go  to  sleep.  Certain  patients  revolt 
because  they  find  that  in  this  way  the  day  seems  to  be  interminable  to 
them.  Then  make  them  understand  that  this  appearance  corresponds 
to  a  therapeutic  reality,  and  that  if  the  day  seems  to  them  to  have  forty- 
eight  hours  it  is  really,  from  the  point  of  view  of  the  withdrawing  of 
pathological  phenomena  and  from  the  forgetting  of  the  symptoms 
presented,  as  if  it  had  lasted  the  apparent  time.  In  some  cases,  and 
among  those  patients  who  cannot  seem  to  get  to  the  point  of  checking 
their  thoughts  in  this  way,  one  can  bring  about  a  state  of  intellectual 
repose  by  means  of  work,  paradoxical  as  this  may  seem.  You  can 
occupy  your  patients  with  intellectual  work  of  some  mechanical  nature. 


THE  ADJUVANTS  OF  PSYCHOTHERAPY.      317 

It  would  seem  as  though  the  blissful  game  of  patience  of  our  youth 
had  been  rejuvenated  under  the  form  of  puzzles  for  the  special  benefit 
of  neurasthenics.  Sometimes  reading  some  light  novel  will  offer  suffi- 
cient intellectual  rest.  But  for  mental  rest,  as  well  as  for  physical 
rest,  the  important  thing  to  take  into  consideration  is  this  fact, — namely, 
that  the  chief  factor  of  fatigue  in  all  normal  sick  individuals  is  neither 
movement  nor  work,  but  rather  agitation  or  cerebral  tension. 

When  it  comes  to  be  a  question  of  moral  rest,  certain  physicians 
think  that  they  have  solved  the  whole  problem  by  saying  to  their  pa- 
tients, ^*Do  something  to  distract  yourself;  take  a  journey."  There  are 
some  who  are  content  to  say  simply,  ''Don't  dwell  upon  the  things  that 
trouble  you."  The  advice  is  excellent,  but  often  not  at  all  easy  to 
follow!  Here  the  physician's  help  should  be  much  more  direct.  It  is 
necessary  for  him,  having  learned  something  about  the  patient's  life, 
to  direct  his  manner  of  living,  temporarily,  at  least  for  the  time  neces- 
sary for  his  cure.  If  the  patient  occupies  some  particular  social  position, 
he  must  be  relieved  of  it  in  such  a  way  that,  concerning  that  thing  at 
least,  he  is  perfectly  tranquil.  If  he  has  children,  he  must  intrust  them 
to  some  relative  in  whom  he  has  absolute  confidence.  The  physician 
must  think  about  all  these  things,  and  plan  for  them,  in  order  to  be 
sure  that  the  moral  rest,  which  he  considers  necessary,  may  be  effectively 
accomplished,  and  that  the  patient,  feeling  a  sense  of  security  as  re- 
gards the  present,  has  only  to  forget  the  past  and  to  strengthen  himself 
for  the  future.  All  these  ideas  are  evidently  simply  an  expression  of 
good  sense,  but,  if  we  are  to  believe  what  we  have  seen,  they  are  very 
seldom  put  into  practice.  As  a  matter  of  fact,  we  have  seen  a  great 
many  patients  to  whom  excellent  advice  has  been  given,  but  not  the 
means  of  following  it. 

Absolute  rest  can  practically  be  accomplished  only  by  strict  isolation. 
The  patient  who  has  been  promised,  and  who  has  confidence  in  the 
word  of  the  speaker,  that  if  anything  happens  to  any  of  his  family  he 
will  be  told  of  it  immediately,  but  who  does  not  receive  any  kind  of 
excitement  whatsoever  of  an  outside  origin,  will  naturally  find  himself 
in  the  best  situation  to  acquire  internal  calmness,  which  is  the  ideal 
form  of  repose. 

This  should  apply  to  every  degree  of  rest.  It  is  a  question  of  making 
arrangements  and  taking  the  minutest  care  on  the  part  of  the  physician. 

Overfeeding  is  an  adjunct  which,  when  one  finds  that  it  is  indicated, 
should  be  applied  in  a  much  more  systematic  way.  In  the  great  majority 
of  cases  we  still  find  that  a  partial  or  absolute  milk  diet  gives  the  best 
results. 

Cases  where  milk  cannot  be  tolerated  are  met  with  only  in  the 
smallest  numbers.  An  intolerance  which  lasts  sufficiently  long  and  is 
so  marked  that  one  is  obliged  to  give  up  a  milk  diet  has  not  been  met 
with  by  us  in  more  than  the  proportion  of  one  in  two  or  three  hundred 


318      THE  TREATMENT  OF  PSYCHONEUROSES. 

cases,  in  an  experience  of  dealing  with  thousands  of  patients.  What 
one  sees  most  often  are  patients  who  complain  of  bitterness  or  dis- 
tention, clamminess  of  the  mouth,  diarrhœa,  or  constipation.  These 
phenomena,  which  last  as  a  rule  for  only  a  few  days,  are  not  necessary 
to  be  considered. 

It  is  our  custom  to  make  our  patients  take  milk  from  hour  to  hour 
in  increasing  quantities  twelve  times  a  day.  We  begin  by  making  them 
take  three  quarts  the  first  day,  perhaps  two  hundred  and  fifty  drachms 
an  hour;  then  w^e  increase  the  hourly  dose  in  such  a  way  as  to  attain 
the  quantity  of  three  and  a  half  to  four  quarts,  and  finally  get  up  to 
the  amount  of  five  quarts  a  day,  beyond  which  we  rarely  go.  We  get 
up  to  this  last  quantity  in  eight  or  ten  days. 

The  great  advantage  of  this  milk  diet  is  that  it  does  not  require  any 
very  great  effort  to  take  it.  A  cup  of  milk  is  easily  swallowed.  Pa- 
tients will  readily  consent  to  such  a  diet  of  overfeeding  who  would 
refuse  to  eat  bountiful  or  frequent  meals. 

It  must  not  be  forgotten  that,  as  a  matter  of  fact,  our  patients 
are  most  often  apt  to  be  in  a  state  of  very  marked  and  sometimes  ex- 
tremely pronounced  dénutrition.  Now,  as  they  have  more  or  less  lost 
their  appetite,  and  under  these  conditions,  if  at  the  beginning  of  their 
treatment  it  is  difficult  and  perhaps  almost  impossible  for  them  to  take 
solid  food  in  sufficient  quantity  not  only  to  nourish  them,  but,  more 
than  that,  to  increase  their  weight,  it  is,  however,  always  easy  for  them 
to  drink.  The  practice  of  milk  régime  from  the  start  of  the  treat- 
ment is,  moreover,  the  only  process  which  can  give  such  remarkable — 
we  might  almost  say  such  unbelievable — increase  in  weight  as  we  are 
constantly  obtaining,  and  which,  as  ahnost  a  regular  thing,  amounts  to 
from  1500  to  1800  grammes  (3  to  3.5  pounds)  a  week,  and  goes  up  in 
cases  which  are  rare  but  not  exceptional  to  as  high  as  6  or  8  or  even  10 
pounds  during  the  first  week.  Do  we  mean  by  this  that  we  attach  any 
doctrinal  value  to  the  practice  of  overfeeding  on  a  milk  diet?  By  no 
means.  Our  experience  has  simply  proved  that  this  is  the  easiest  method 
and  the  one  that  is  surest  and  most  efficacious. 

Other  methods  of  overfeeding,  apart  from  the  fact  that  they  are 
not  always  free  from  danger  to  the  liver  and  kidneys  of  the  patient, 
hardly  ever  give  the  same  results. 

Let  us  add,  finally,  that  in  a  certain  number  of  cases,  and  par- 
ticularly in  those  where  overfeeding  does  not  necessarily  seem  to  be 
urgent  as  a  therapeutic  measure,  we  are  perfectly  willing  to  confine 
these  rules  for  overfeeding  to  heartier  and  more  frequent  meals,  with- 
out any  other  regime. 

Physical  and  mental  rest  as  well  as  overfeeding  are,  however,  not 
absolutely  necessary  elements  of  the  treatment  of  a  psychoneurosis, 
any  more  than  isolation.  It  all  depends  on  the  nature  of  the  case,  for 
the  indications  are  determined  by  the  existence  of  this  or  that  functional 


THE  ADJUVANTS  OF  PSYCHOTHERAPY.      319 

manifestation.  The  only  thing  that  seems  to  us  absolutely  and  always 
necessary  is  the  moral  rest, — ^that  is,  the  effort  made  by  the  physician 
and  by  the  patient  to  avoid  the  onset  of  new  emotions  which  are  liable 
to  upset  the  patient  again  and  to  interrupt  the  psychotherapeutic  action. 
It  is  impossible  to  give  the  patient's  mind  a  new  direction,  to  lay  dowù 
for  him  new  paths  of  thought,  so  to  speak,  in  any  given  direction,  if 
he  is  constantly  subjected  to  the  continual  action  of  real  preoccupa- 
tions corresponding  to  some  effective  cause.  Naturally,  in  many  cases 
these  matters  are  not  easy  to  arrange.  One  has  to  ask  the  patient  to 
temporarily  lose  his  interest  in  a  whole  series  of  facts  which  are  apt  to 
add  their  depressing  influence  to  his  preoccupation  and  to  the  old 
emotions  which  originally  brought  on  his  disease.  In  holding  before  his 
eyes  the  hope  of  a  cure,  one  is  often  able  to  obtain  from  him  this  sacrifice, 
which  elsewhere  is  practically  brought  about  by  isolation,  which  is  the 
only  thing  that  makes  it  possible  to  really  lose  interest  in  oneself. 

There  are  many  other  helps  in  the  therapy  of  a  psychoneurosis.  We 
shall  have  occasion  to  point  them  out  as  we  go  along,  when  in  a  little 
while  we  shall  take  up  the  study  of  the  treatment  of  the  functional 
manifestations.  But  the  thing  that  we  hope  will  be  retained  from  the 
preceding  pages  is  that  in  the  treatment  of  a  psychoneurosis,  without 
this  psychotherapeutic  action  which  is  the  only  absolutely  fundamental 
thing,  and  which  is  always  necessary  to  employ,  there  is  no  possible 
therapeutic  systematization. 

If  we  have  devoted  a  whole  chapter  to  the  study  of  isolation,  rest, 
and  overfeeding,  it  is  because  these  agents  are  employed  under  a  great 
number  of  circumstances.  They  in  themselves  never  constitute  a  suffi- 
cient psychotherapy,  while,  inversely,  the  psychotherapeutic  treatment 
may,  without  any  other  aid,  cure  a  comparatively  great  number  of 
patients. 

No  independent  treatment,  such  as  dietetic  treatment  alone  or  isola- 
tion or  rest  based  on  some  systematic  method,  or  any  such  common 
formula,  can  fill  the  varied  and  multiple  requirements  of  the  treatment 
of  our  patients. 


CHAPTER  XXIV. 

SPECIAL  THER.\PY  OF  THE  VARIOUS  FUNCTIONAL   MANIFESTATIONS. 

If  general  psychotherapy  of  the  mental  and  moral  status  of  the 
neurasthenic  consists  in  a  single  therapy  common  to  all  patients  afflicted 
with  psychoneuroses,  and  if  the  same  principles  of  treatment  for  the 
functional  manifestations  are  susceptible  to  a  general  application,  it  is 
no  less  true  that  each  particular  functional  manifestation  calls  forth 
indications  for  special  treatment.  This  is  particularly  the  case  with 
the  processes  of  re-education,  which  evidently  cannot  be  the  same  when 
one  is  treating  the  case  of  an  asthenic,  or  a  false  gastropath,  or  a  false 
urinary. 

Taking  up  the  whole  series  of  functional  manifestations  as  we  have 
described  them  in  the  first  part  of  this  work,  let  us  glance  successively 
at  those  particular  therapeutic  agents  which  have  seemed  to  us  to  be 
beneficial.  It  goes  without  saying  that  any  treatment  of  a  functional 
trouble  must  be  accompanied  by  treatment  of  the  underlying  moral 
and  mental  condition  on  which  the  symptom  has  been  grafted. 

I.  Functional  Manifestations  in  the  Digestive  Organs. 

A.  Disturbances  of  the  Appetite. — Of  all  the  functional  manifesta- 
tions of  which  the  digestive  apparatus  is  the  seat,  the  most  serious  and 
that  which  requires  the  most  prompt  and  specialized  treatment  is  un- 
doubtedly mental  anorexia.  This  is  because,  although  mental  anorexia 
is  a  psychoneurosis  as  far  as  its  cause  is  concerned,  its  results  express 
themselves  in  one  of  the  most  serious  organic  conditions.  Whether  one 
has  to  treat  a  patient  who  is  extremely  emaciated,  or  whether  the 
anorexia  be  primary  or  secondary,  before  any  other  kind  of  psycho- 
therapeutic treatment  can  be  begun,  it  is  extremely  important  to  isolate 
the  patient  and  to  feed  him. 

We  do  not  hesitate  to  say  emphatically  that  it  is  impossible  to  treat 
mental  anorexia  in  the  family  circle,  and  that  to  attempt  it  is  to  run 
the  risk  of  certain  failure,  of  which  the  patient's  death  may  be  the 
outcome.  This  is  because  the  family  give  in  too  easily  to  their  patient, 
and  do  not  know  how  to  insist  upon  the  kind  of  feeding  that  is  neces- 
sary. Furthermore,  it  often  happens  that  the  anorexic  patient  seems 
to  get  a  great  deal  of  satisfaction  out  of  complaining  about  his  food,  and 
of  getting  his  family  to  intercede  for  him,  and  this,  when  the  treatment 
is  not  sufficiently  well  systematized,  leads  to  a  continuous  loss  of  weight 
which  he  will  look  upon  with  a  sense  of  triumph.  Isolation  is,  there- 
fore, imperative,  and  in  such  cases  it  must  be  strict  isolation.  The  de- 
320 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.        321 

sire  to  shorten  its  duration  may  sometimes  of  itself  be  enough  to  induce 
the  patient  to  consent  all  the  sooner  to  take  food. 

As  far  as  the  alimentation  itself  is  concerned,  there  are  two  classes 
of  patients  who  may  be  met  with.  Some  are  so  feeble  that  one  hardly 
dares  to  disturb  them.  Here  it  is  necessary  to  carry  on  the  feeding  in  a 
very  slow  and  progressive  manner.  One  may  sometimes  not  be  able 
to  give  during  the  first  day  more  than  a  few  teaspoonfuls  of  milk  every 
five  or  ten  minutes,  or  every  quarter  of  an  hour,  and  to  increase  little 
by  little,  but  in  a  way  which  is  nevertheless  rapid,  the  amount  of  each 
feeding.  If  on  the  first  day  it  was  only  possible  to  give  the  patient 
from  six  to  nine  ounces  of  milk,  on  the  second  day  one  ought  to  be  able  to 
get  him  to  take  a  pint  and  a  half,  on  the  third  three  pints,  and  finally 
get  to  the  point  in  eight  or  ten  days  where  he  will  take  a  regular  quan- 
tity of  five  quarts  of  milk,  which  amount  should  be  maintained  until 
the  patient  has  regained  his  normal  weight, — ^that  is  to  say,  during  a 
number  of  weeks,  which,  of  course,  would  vary  in  different  cases.  At 
this  point  one  may,  any  day,  put  him  upon  an  ordinary  regular  diet. 

Among  patients  who  are  still  vigorous,  as  are  the  majority  of  the 
primary  anorexias,  one  manages  in  three  or  four  days  to  get  to  the  point 
where  one  can  give  the  classic  amount  to  what  constitutes  overfeeding 
in  a  milk  diet.  If  necessary, — that  is,  if  the  patient  refuses  to  take 
the  quantity  of  milk  which  is  prescribed, — one  should  proceed  ener- 
getically. One  may  threaten  the  patient  with  the  feeding-tube,  and  if 
necessary  use  it.  If  he  makes  himself  vomit  afterward,  as  often  hap- 
pens, one  must  simply  begin  the  gavage  over  again  as  soon  as  he  is 
through.  The  very  important  thing  is  not  to  give  in.  As  a  matter  of 
fact,  however,  when  the  physician's  authority  is  sufficiently  well  estab- 
lished, it  is  very  seldom  that  one  is  obliged  to  have  recourse  to  such 
extreme  measures,  because,  when  he  feels  that  he  has  to  do  with  some- 
body who  is  stronger  than  himself,  the  patient  generally  submits. 

It  may  happen  that,  among  certain  patients  who  are  extremely  weak, 
one  is  obliged  to  seek  for  aid  from  ordinary  medical  therapy;  one  may 
thus  have  to  give  injections  of  serum,  or  hypodermics  of  caffeine,  or 
camphor  oil,  to  warm  the  patient  by  artificial  means.  These  are  urgent 
therapeutic  measures  such  as  are  applied  to  people  in  the  last  stages  of 
starvation  and  subjects  who  are  at  the  point  of  death. 

In  such  patients  psychotherapy  must  not  be  omitted  at  the  start  if 
the  patients  are  strong  enough,  or  if  they  have  passed  the  most  serious 
point  in  the  disease  where  the  danger  of  an  unfortunate  outcome  has 
been  avoided;  it  is  necessary  then  to  try  to  find  out,  in  the  different 
ways  that  we  have  indicated,  the  emotional,  moral,  or  psychical  causes 
of  the  anorexic  conditions.  We  do  not  insist  on  this  point.  The  question 
here  is  one  of  the  general  psychotherapy  of  the  psychoneuroses. 

But  the  psychic  therapy  of  anorexics  demands  some  special  indica- 
tions. These  patients  must  be  made  to  understand  that  just  as  long  as 
21 


322      THE  TREATMENT  OF  PSYCHONEUROSES. 

they  try  to  practise  deceptions  concerning  their  food  they  will  not  be 
cured.  We  are  accustomed  to  tell  our  patients  that  the  triumph  for 
them  lies  not  in  merely  succeeding  to  take  the  least  little  bit  from  the 
plate  of  meat  set  before  them,  but  rather  in  making  up  their  mind,  by 
an  effort  of  will  at  first  and  then  spontaneously  later,  to  choose  if  not 
the  largest  piece  at  least  one  of  fairly  good  size. 

If  the  patients  have  really  understood  the  mechanism  of  their  dis- 
ease, which  at  some  time  you  must  have  explained  to  them,  if  you  have 
succeeded  by  an  emotional  reaction  in  penetrating  sufficiently  into 
their  mentality,  it  is  rare  if  they  do  not  rapidly  comprehend  your 
point  of  view.  At  first  with  effort,  but  later  quite  naturally,  they  will 
eat  heartily  and  in  sufficient  quantities. 

Under  these  conditions  one  has  no  need  to  fear  a  relapse.  It  would, 
however,  be  almost  fatal  if  after  having  made  your  patient  gain  a 
certain  number  of  pounds  you  should  leave  him  without  having  modified 
his  mentality. 

When  you  send  such  patients  home  to  their  families,  you  must  warn 
them  that  no  matter  what  happens,  and  no  matter  how  much  advice 
is  given  to  them  on  the  subject,  they  must  never,  except  of  course  in 
very  serious  illness,  consent  to  go  upon  a  restricted  diet. 

Outside  of  the  mental  anorexias  which  are  sharply  defined,  there  are 
a  great  number  of  cases  of  minor  anorexia  where  almost  imperceptibly, 
and  by  very  easy  stages  by  the  slow  but  progressive  restriction  of  their 
diet,  subjects  are  gradually  in  the  way  of  developing  a  characteristic 
anorexia.  Here  a  very  rigid  therapy  is  not  necessary,  at  least  at  the 
start,  and  it  is  generally  enough  to  make  the  patient  understand  the 
danger  which  threatens  him,  and  to  put  him  upon  a  hearty  diet,  in 
order  for  him  to  regain  rapidly  the  few  pounds  which  he  has  lost. 

As  far  as  unnatural  cravings  for  certain  foods  and  over- voracious 
appetites  and  elective  anorexias  are  concerned,  they  do  not  demand  any 
special  indications  except  in  so  far  as  re-education  is  concerned,  which 
ought  to  be  carried  on  progressively.  One  must  limit  those  with  a 
voracious  appetite  to  a  certain  quantity  of  food  to  be  taken  at  each 
meal.  Then  one  must  diminish  the  number  of  meals.  As  for  the 
elective  anorexias,  one  must  ask  that  the  patients  should  add  to  their 
diet,  which  has  been  restricted  as  regards  kind,  at  first  a  few  and  a 
small  quantity  and  then  a  greater  number  and  a  greater  quantity  of 
the  foods  which  they  have  been  accustomed  to  refuse. 

B.  Disturbances  of  the  First  Three  Stages  of  Digestion. — ^We  have 
seen  that  in  this  class  of  functional  manifestations  there  are  two  marked 
classes  of  patients.  One,  which  is  by  far  the  most  numerous,  is  com- 
posed of  true  phobies  of  deglutition,  who  do  not  dare  to  swallow.  The 
other  includes  a  very  much  smaller  number  of  patients  who  after  having 
swallowed  their  food  are  seized  with  spasm  of  the  oesophagus.    We  may 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.         323 

divide  the  first  group  of  patients  into  three  classes.  It  may  happen 
that  the  alimentary  restriction  in  relation  to  the  phobic  phenomena  has 
been  sufficiently  great  to  bring  the  patient  into  a  state  of  true  mental 
anorexia.  The  isolation  and  the  process  of  treatment  applied  to  this 
last  manifestation  are  then  imposed. 

Under  other  circumstances  isolation  will  often  be  indicated  because 
in  his  environment  the  patient  will  find  elements  which  will  bring  back 
and  call  up  and  encourage  the  functional  manifestation.  Until  he  is 
cured,  it  will  be  necessary  for  him  to  avoid  the  daily  life  in  which  his 
first  symptoms  were  called  forth.  Finally,  in  a  certain  number  of  cases 
in  which  these  conditions  are  not  realized,  simple  psychotherapeutic 
treatment  wiU  be  found  to  be  sufficient. 

It  is  clear  that,  the  nature  of  the  symptoms  in  question  having  been 
brought  out  by  the  examination  and  questioning,  the  first  work  of  the 
psychotherapeutist  will  be  to  reassure  the  patient  by  explaining  to  him 
very  carefully  the  nature  of  the  symptoms  which  he  presents.  He  will 
then  have  to  experimentally  confirm  this  conviction,  which  he  has  in- 
duced the  patient  to  accept,  concerning  the  psychic  nature  of  the 
phenomena  which  he  has  experienced.  The  best  method  consists  in 
being  present  at  one  of  the  patient's  meals,  so  that  he  may  feel  a  sense 
of  absolute  safety  that  if  any  accident  happens  to  him  he  will  have 
immediate  help.  But  here  one  must  be  careful  not  to  think  that  he 
ought  continually  to  urge  the  patient  and  encourage  him.  It  more 
often  happens  that  by  doing  this  the  emotional  phenomena  are  recalled, 
and  that  the  patient  shows  more  hesitation  than  ever  before  swallow- 
ing anything.  The  encouragements  and  all  questions  concerning  the 
emotional  element  which  might  upset  the  patient  ought  to  be  before  or 
after  the  experimental  meal.  If  during  this  repast,  however,  one  can 
succeed  in  distracting  the  patient's  attention  in  such  a  way  that  he 
swallows  without  thinking,  this  will  be  the  best  way  of  completely  re- 
assuring him.  It  will  not  always  be  convenient,  and  if  one  does  not 
succeed  in  this  way  one  must  be  content  to  make  the  patient  take  a 
certain  amount  of  food  in  a  given  time.  On  the  following  day,  and  so 
on  progressively,  one  will  increase  the  amount  of  food  while  at  the  same 
time  one  will  diminish  the  allotted  time.  In  some  cases  one  can,  during 
this  process  of  re-education,  recommend  a  rather  varied  diet.  There  is, 
as  a  matter  of  fact,  a  certain  number  of  such  patients  who  can  easily 
swallow  liquid  or  soft  food  and  who  only  have  difficulty  with  solid 
food.  There  are  others  in  whom  the  opposite  phenomena  are  true.  One 
can  for  several  days,  and  during  the  time  when  one  is  carrying  on  the 
most  energetic  psychotherapy,  only  give  the  patient  the  kind  of  food 
which  does  not  excite  any  phobic  symptom  in  him.  One  will  thus  give 
his  emotional  condition  time  to  calm  down.  One  will  permit  the  patient 
in  this  way  to  forget,  so  to  speak,  his  functional  phenomena.     Normal 


324      THE  TREATMENT  OF  PSYCHONEUROSES. 

feeding  may  then  be  taken  up  without  any  transition,  and  will  often 
be  readily  borne. 

At  all  events,  the  treatment  could  not  be  considered  as  finished  until, 
either  by  psychotherapeutic  or  experimental  conviction,  the  swallowing 
can  be  accomplished  quite  spontaneously. 

Concerning  spasms  of  the  œsophagus  a  very  important  distinction 
must  be  made.  They  are  not  all  directly  and  exclusively  amenable  to 
psychotherapy.  There  are  very  serious  spasms  (Gruisez)  in  which 
organic  modifications,  consisting  essentially  of  dilatation  of  the  hypo- 
pharynx  or  of  the  œsophagus,  with  a  more  or  less  acute  inflammatory 
condition,  follow  the  functional  trouble  and  make  it  worse.  In  such 
cases,  when  the  organic  modifications  have  not  yielded  to  appropriate 
treatment  which  belongs  to  the  work  of  a  specialist,  it  is  useless  to  try 
a  psychic  treatment,  which  by  itself  would  be  wholly  inefficacious. 
Progressive  dilatation  may  be  indicated,  and  psychotherapy  would  only 
come  in  as  a  secondary  element  to  reassure  the  patient  and  to  avoid 
relapses. 

In  recent  or  mild  cases  psychotherapy  and  methods  of  re-educa- 
tion would,  on  the  other  hand,  be  enough  to  assure  the  disappearance 
of  the  functional  trouble.  Here  again,  following  the  circumstances  which 
have  preceded  the  appearance  of  the  trouble  and  those  which  seem  to 
be  persistent,  isolation  may  or  may  not  be  indicated. 

It  is  rather  rare  in  such  cases  that  all  foods  should  cause  a  spasm. 
However,  in  the  case  of  serious  spasms,  when  the  spasm  which  is  in- 
creased by  local  symptoms  has  become  permanent,  it  has  occurred  only 
as  a  consequence  of  a  psychic  impression.  When  a  patient  has  taken 
some  food  concerning  which  he  has  felt  perfectly  safe,  no  symptom  is 
produced.  One  should  remember  this  fact,  as  it  is  an  aid  in  re-educa- 
tion. One  should  allow  the  patient  time  to  feel  the  general  psycho- 
therapeutic influence  by  feeding  him  at  first  only  with  what  he  can 
tolerate,  in  order  not  to  encourage  a  susceptibility  which  is  going  to 
diminish  gradually  under  psychotherapeutic  influence. 

There  are  even  some  subjects  whose  attack  is  so  slight  that  a  single 
psychotherapeutic  conversation  may  cause  all  their  troubles  to  disap- 
pear, and  the  patient  can  go  home  and  eat  like  anybody  else. 

C  Gastric  Manifestations  of  Nervous  People. — The  course  to  be 
pursued  varies  according  to  whether  the  patient  has  the  simple  dyspeptic 
troubles  of  a  neurasthenic,  or  gastric  phobias,  or  characteristic  pseudo- 
gastropathy,  or  neuropathic  vomiting. 

The  simple  dyspeptic  disturbances  of  the  neurasthenic  do  not  re- 
quire any  special  therapy.  Moreover,  they  generally  form  merely  an 
accessory  in  the  sjnnptomatic  ensemble.  All  that  we  have  said  of  the 
general  psychotherapy  of  the  neurasthenic  and  the  general  psychotherapy 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.        325 

of  a  functional  manifestation  may  be  applied  without  comment  to  these 
disturbances. 

Two  different  therapies  may  be  applied,  according  to  circumstances, 
to  the  stomach  phohias.  If  a  physician  has  sufficient  authority  over 
his  patient,  he  may  at  the  outset  of  a  single  conversation  so  stir  him 
up  that  he  can  get  him  to  throw  over  all  his  purely  subjective  fears. 
But  it  often  happens  that  a  physician's  influence  is  not  at  first  suffi- 
ciently strong,  or  that  the  patient's  systematization  has  been  too  long 
established  and  too  crowded  with  all  kinds  of  associations.  One  must 
then  go  more  slowly,  and  take  up  progressively  the  alimentary  re-educa- 
tion of  the  patient.  At  the  start,  one  must  be  prudent,  and  must  com- 
mence by  the  diet  which  the  patient  thinks  is  the  only  one  that  he  can 
tolerate,  and  must  make  only  very  slight  additions.  But,  just  in  pro- 
portion as  the  mentality  of  the  patient  changes  in  response  to  the  ex- 
periment, one  may  become  a  little  bolder.  The  patient  who  would  have 
cried  out  a  little  while  before  at  any  slight  change  in  his  food  régime, 
**0h,  my  stomach  could  never  stand  all  that,"  is  already  at  the  point 
where  he  no  longer  feels  astonished  at  having  you  propose  an  almost 
radical  transformation  of  his  usual  diet.  There  are  even  great  numbers 
of  patients  who,  having  been  made  happy  at  their  first  trial  of  the 
general  psychotherapeutic  action,  have  themselves  gone  upon  a  regular 
diet.  Either  at  the  start  or  after  a  little  time,  which  rarely  exceeds  a 
fortnight  or  three  weeks,  such  patients  are  cured. 

The  therapeutic  action  is  by  no  means  so  easy  to  obtain  in  cases  of 
characteristic  pseudo-gastropathies.  The  systematization  of  the  patient  in 
general,  which  is,  moreover,  reinforced  by  former  therapeutic  measures, 
is  extremely  strong.  The  symptomatology  is  loaded  with  phenomena 
which,  as  we  have  already  seen,  have  an  objective  reality,  and  make  a 
great  impression  on  the  patient.  A  whole  series  of  associations  of  all 
kinds  is  formed,  and  the  pathological  idea  is  hung,  as  it  were,  upon  all 
the  constituent  elements  of  the  patient's  condition  due  to  his  surround- 
ings. More  often  isolation — and  very  rigorous  isolation — is  distinctly 
indicated.  It  is  all  the  more  apt  to  be  the  case  with  those  patients  who 
are  very  much  morally  or  physically  depressed,  and  in  the  state  of 
subcontinuous  emotionalism,  and  who  are  in  real  need  of  that  absolute 
rest  which  can  be  assured  only  by  isolation. 

For  such  patients  the  part  of  re-education,  which,  however,  is 
effective,  does  not  appear  to  us  to  be  less  necessary,  but  rather  secondary. 
Their  moral  and  mental  condition  is  generally  so  bad,  and  such  a  great 
number  of  symptoms  presented  by  them  might  be  considered  as  emotional 
gastric  fixations,  that  in  their  treatment  general  psychotherapy  must 
play  the  most  important  part.  In  proportion  as  the  moral  condition  of 
these  patients  is  improved  there  is  a  marked  quieting  down  of  their 
gastric  troubles.  If  one  makes  a  simultaneous  attack  upon  the  psychic 
conditions  which  have  directed  the  patient  to  turn  his  attention  upon 


326      THE  TREATMENT  OF  PSYCHONEUROSES. 

his  stomach,  it  is  not  an  unusual  thing  for  one  to  be  able  to  work  a 
rather  rapid  cure.  It  goes  without  saying  that  one  will  find  certain 
phenomena  persisting  for  a  rather  long  time,  such  as  those  phenomena 
which  like  atony  are  due  to  poor  general  condition  resulting  from  lack 
of  food,  or  troubles  which  depend,  if  one  might  put  it  so,  upon  the  bad 
secretory  or  motor  habits  which  have  become  fastened  upon  the  patient 
for  months  or  years  under  some  psychic  influence.  However,  the  per- 
sistence of  these  manifestations,  expressing  themselves  by  a  certain  bit- 
terness or  feeling  of  heaviness  or  gas,  etc.,  is  never  prolonged  for  any 
length  of  time.  It  is  all  the  more  apt  to  be  less  when  the  general  con- 
dition of  the  patient  has  been  improved  by  having  sufficient  nourish- 
ment. 

The  restoration  of  the  patient  to  normal  nourishment  does  not  always 
take  place  without  some  set-backs,  and  it  is  then  that  one  must  resort 
to  dietetic  re-education.  This  ought  to  be  based  upon  the  exact  knowl- 
edge of  the  mechanism  which  was  present  at  the  time  when  the  patient 
began  to  choose  or  suppress  certain  articles  in  his  dietary  régime  (see 
Part  I,  Chapter  I,  p.  10). 

It  is  quite  certain  that,  in  a  very  large  majority  of  cases,  it  would 
be  imprudent,  at  least,  to  expect  to  get  false  gastropaths,  whose  psychism 
has  been  for  long  years  centred  upon  their  stomach,  suddenly  to  give 
up  altogether  the  dietetic  régime  which  they  have  followed  until  that 
day.  It  would  be  no  more  reasonable  than  to  ask  an  hysterical  hémi- 
plégie or  astasic-abasic  to  recover  instantaneously  his  movements  or  his 
equilibrium.  One  must  gradually  change  the  patient's  food  régime; 
conquests  must  be  made  day  by  day  and  the  progress  be  slow  but 
regular.  Under  this  condition  only  will  the  results  obtained  be  definite. 
And  although,  in  some  cases,  physicians  who  have  considerable  influence 
over  their  patients  have  been  able  to  induce  them  to  change  suddenly 
their  alimentary  hygiene,  we  have  been  able  to  establish  the  fact  for 
ourselves  that,  although  some  brilliant  results  have  been  obtained,  they 
are  very  apt  to  be  followed  by  set-backs,  of  which  the  most  serious  con- 
sequence is  to  fix  the  patient's  mind  still  more  firmly  upon  his  disease, 
to  anchor  the  conviction  of  his  gastropathy  still  more  firmly,  and  to 
make  it  more  difficult  to  get  back  to  a  normal  life. 

We  might  add,  however,  that  patients  who  have  suffered  sometimes 
for  years — and  we  have  seen  those  whose  affection  dated  back  for 
twenty-five  or  thirty  years — do  not  care  much  whether  the  treatment 
takes  several  weeks  more  or  less.  Furthermore,  we  must  frankly  say 
that  when  the  cure  has  been  slow  and  difficult  to  obtain  there  is  more 
chance  of  its  lasting.  The  chief  thing  is  that  the  patient  ought  to  be 
told  beforehand  about  how  much  time  it  will  take  to  bring  him  back  to 
his  original  condition,  so  that  one  may  avoid  in  this  way  any  possibility 
of  disappointing  him. 

It  is  very  certain  that  the  first  thing  of  all  to  combat  is  the  actual 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.        327 

insufficiency  of  food,  regardless  of  its  quality.  It  is  necessary  to  induce 
the  patient  to  go  upon  such  a  régime  that  his  weight,  instead  of  steadily 
diminishing  as  it  has  done  hitherto,  will  perceptibly  increase.  This  is 
the  first  end  which  one  must  have  in  view  before  anything  else. 

But,  in  order  not  to  multiply  one's  difficulties,  it  will  be  absolutely 
useless  to  give  the  patient  many  different  foods  at  once.  At  this  period, 
at  the  start  of  the  treatment,  in  the  greatest  number  of  cases,  milk  taken 
in  small  repeated  doses  is  the  thing  which  will  fill  the  greatest  number 
of  requirements.  Starting  with  a  dose  of  three  quarts,  in  a  few  days 
one  can  increase  it  to  four  or  five  quarts.  This  exclusive  milk  diet  in 
large  quantities  ought  to  be  kept  up  from  a  week  to  a  month,  some- 
times longer,  according  to  the  manner  in  which  the  patient  has  been 
able  to  tolerate  it,  and  according  to  the  psychic  modification  which  has 
been  obtained  by  contemporaneous  psychotherapeutic  treatment. 

The  practical  result,  from  our  point  of  view,  of  this  whole  period  is 
to  show  the  patient  that  he  can  digest  a  large  quantity  of  food,  a  quan- 
tity which  in  any  case  is  enough  to  make  him  gain  weight  (from  eight 
to  fifteen  pounds  at  least  in  three  or  four  weeks).  He  will  not  refrain 
from  telling  you  that  this  food  has  been  digested  by  him,  because  it  was 
nothing  but  milk  and  liquid  diet.  After  the  quantitative  re-education 
has  been  accomplished,  we  insist  that  it  must  be  followed  by  qualitative 
re-education,  and  just  here,  when  we  come  to  struggle  against  all  the 
notions  concerning  the  quality  of  food,  we  must  proceed  with  more  or 
less  circumspection,  because  it  is  often  just  at  this  point  that  one  is 
apt  to  meet  the  greatest  difficulties. 

In  regard  to  the  individual  variations  which  one  may  observe  and 
to  which  one  should  lend  the  greatest  consideration,  the  attitude  to 
take  in  the  conduct  of  reconstruction  of  normal  alimentation  should  be 
based  on  the  exact  knowledge  of  the  psychical  mechanism  according  to 
which  in  the  particular  case  the  progressive  restriction  of  diet  has  been 
brought  about.  It  is  no  less  true  that,  as  a  rule,  the  ideas  which  have 
been  developed  from  what  we  have  said  in  the  first  part  of  our  book 
are  practically  sufficient.  That  is  to  say,  in  other  words,  that  one  should 
avoid  letting  the  patient  be  conscious  of  any  effort  in  the  matter  of 
taking  food.  For  the  constituent  elements  of  psychic  sensation  of  tHe 
effort  of  eating  have  already  been  enumerated  by  us.  They  are  all 
rather  active  sensorial  impressions.  All  these  mechanical  difficulties  of 
mastication  or  of  deglutition  are  rather  vivid  sensorial  impressions. 

Therefore,  in  this  progressive,  systematic  re-education  which  we  are 
pursuing,  we  must  begin  with  semi-liquid  food  that  is  not  at  all  greasy 
nor  highly  seasoned.  From  this  point  of  view,  eggs,  milk  toast, 
vegetables,  and  minced  meats  that  are  not  highly  seasoned  fill  the  need. 
It  may  be  a  matter  of  some  days  before  one  can  work  up  to  a  beef- 
steak or  a  lamb  chop  every  other  day.  A  week  or  perhaps  a  fortnight 
later  you  will  have  been  able  progressively  to  re-accustom  your  patient 


328      THE  TREATMENT  OF  PSYCHONEUROSES. 

to  an  ordinary  diet.  He  will  eat,  without  any  fear  and  without  any 
pain,  absolutely  everything  set  before  him.  There  are  cases — and  they 
are  not  rare^ — where  one  has  been  able  from  one  day  to  another,  with- 
out any  transition  whatever,  to  make  the  patient  pass  from  his  milk 
diet  over  to  an  ordinary  diet. 

And  if  you  have  been  careful  to  make  your  patient  grasp  the  nature 
and  the  reason  of  the  progress  which  he  has  made  from  the  start  of 
the  treatment,  or  possibly  later,  when  you  have  gained  his  confidence  by 
your  first  success,  you  may  consider  the  cure  as  completely  established 
and  absolutely  definite  in  the  great  majority  of  cases. 

During  the  course  of  this  re-education  of  the  stomach,  it  sometimes 
happens  that  a  relapse  occurs,  and  that  some  food  which  is  well  tolerated 
at  first  will  be  refused  another  time.  One  must  then  find  out  what  are 
the  psychic  reasons  which  determined  this  refusal,  and  what  is  the 
exact  nature  of  the  accident  which  has  produced  it.  Often  it  is  a 
question  of  preconceived  ideas  concerning  the  digestibility  of  such  and 
such  a  food,  against  which  one  must  sometimes  struggle.  Sometimes 
one  can  get  over  the  difficulty  by  making  the  patient  take  the  same 
food  under  a  different  form,  and  to  use  the  favorable  result  obtained 
as  an  argument  for  psychotherapy. 

We  might  report  a  very  great  number  of  cures  obtained  by  follow- 
ing such  a  method,  and  continued  for  long  years.  Simply  to  fix  these 
ideas  we  will  quote  the  case  of  just  one  man  fifty-two  years  of  age, 
who  had  suffered  from  his  stomach  for  fifteen  years,  and  who  was 
extremely  emaciated,  in  whom  the  diagnosis  of  neoplasm  had  been 
made. 

Here  are  the  successive  dietary  régimes  which  we  prescribed  for 
him: 

First  week,  four  quarts  of  milk. 

Second  week,  five  quarts  of  milk. 

Third  week,  four  quarts  of  milk,  four  eggs;  morning  and  evening 
100  grams  of  raw  meat  in  bouillon. 

Fourth  week,  three  quarts  of  milk.  The  re-establishment  of  regular 
meals  at  noon  and  evening,  with  roast  meat,  purée  of  vegetables,  simple 
desserts,  eggs,  and  stewed  fruits. 

Fifth  week,  regular  diet. 

At  the  end  of  two  months  this  patient  was  able  to  take  up  the  work 
by  which  he  and  his  family  lived.  For  four  years,  on  account  of  a 
gastropathy  which  had  no  existence,  he  had  been  obliged  to  give  up  his 
work  altogether. 

Thus,  as  we  have  already  said,  it  is  not  necessary  to  believe  that  one 
must  always  proceed  very  slowly  in  the  re-education  of  the  stomach 
once  the  milk  diet  has  been  given  up.  There  are  cases,  which  are 
rather  frequent,  where  in  twenty-four  hours,  without  any  transition, 
the  patient  has  been  made  to  pass  from  a  milk  diet  to  an  ordinary  diet. 


THEKAPY  OF  FUNCTIONAL  MANIFESTATIONS.         329 

We  want  to  insist  still  further  on  one  point, — ^namel5^,  that  this  estab- 
lishment of  progressive  dietary  regime  or  a  sudden  return  to  ordinary 
nourishment  is  only  one  part  of  the  treatment  of  these  patients. 

Psychotherapy  practised  during  isolation,  and  basing  its  results 
upon  re-education,  forms  quite  as  important,  if  not  a  more  important, 
part.  It  is  none  the  less  true  that  we  have  been  led  to  ask  ourselves 
whether  many  of  the  results  which  have  been  obtained  by  the  aid  of 
diet,  and  the  treatment  of  patients  who  were  considered  to  be  suffering 
from  organic  affections  of  the  stomach  when  in  reality  they  only  had 
functional  troubles,  did  not  spring  purely  and  simply  from  a  kind  of 
unconscious  re-education  practised  by  the  isolation  of  the  patient,  and 
also,  we  should  not  neglect  to  say,  the  isolation  of  the  physician.  And 
if  the  immediate  results  of  such  treatment  may  seem  good,  their  great 
defect  lies  in  the  fact  that  they  do  not  modify  the  psychic  soil,  which 
is  quite  ready  for  the  cultivation  of  a  new  and  energetic  gastropathy 
the  moment  that  there  occur  the  same  causes  of  a  moral  nature  w^hich 
created  the  initial  state. 

In  so  far  as  Tieuropathio  vomiting  is  concerned,  it  is  very  certain 
that  those  particular  forms  among  them  which  are  the  consequences 
of  emotional  reactions  in  certain  subjects,  are  not  susceptible  to  psycho- 
therapy as  far  as  any  direct  action  is  concerned.  Nevertheless,  it  may 
diminish  the  great  frequency  of  these  manifestations  by  the  super- 
action  of  phenomena  of  suggestibility.  But  here  the  true  therapy  lies 
in  the  psychological  substratum  of  the  patient  himself.  It  is  a  true 
prophylactic  therapy. 

The  kind  of  patient  in  whom  the  vomitings  are  due  to  an  exaggera- 
tion of  peripherical  sensibilities  is  susceptible  of  education.  But,  as  a 
matter  of  fact,  these  patients  do  not  take  care  of  themselves,  because, 
while  thus  afflicted  mth  accidental  manifestations  which  only  slightly 
inconvenience  them,  they  do  not  pay  much  attention  to  them.  It  hap- 
pens, however,  that  by  unfortunate  therapeutic  intervention,  and  by 
the  addition  of  phenomena  of  all  kinds,  they  may  secondarily  become 
false  gastropaths,  with  the  vomiting  as  the  most  marked  symptom. 
They  will  then  respond  to  the  same  treatment  which  is  applied  to  false 
gastropaths. 

As  for  uncontrollable  vomiting  and  habitual  vomitings,  whether 
associated  or  not  with  anuria,  they  come  under  the  heading  of  hysterical 
symptoms,  to  which  we  apply  a  common  therapeutic  study. 

It  remains  for  us  to  glance  at,  in  this  first  series  of  functional 
manifestations,  two  troubles,  merycism  and  aerophagy,  which  present 
rather  peculiar  and  somewhat  analogous  characteristics.  While,  as  a 
matter  of  fact,  in  all  preceding  cases,  we  have  seen  that  the  rôle  of 
the  physician  consisted  chiefly  in  distracting  the  patient  from  his 
functional  manifestations,  yet  here  nothing  of  the  kind  is  true,  for 


330      THE  TREATMENT  OF  PSYCHONEUROSES. 

these  are  neuropathic  disturbances  acquired  by  habit,  but  which  are 
often  unperceived  by  the  patient,  or  to  which  at  least  he  pays  only  the 
slightest  attention;  dwelling  rather  on  the  secondary  phenomena  which 
may  follow  them.  A  patient  attacked  by  merycism  or  aerophagy  is 
not  cured  by  forgetting;  he  is  cured  by  attention.  This  is,  as  a  matter 
of  fact,  although  there  are  a  great  number  of  functional  manifesta- 
tions which  result  from  the  intervention  of  the  psychism  into  the 
automatism,  and  which  it  is  logical  to  cure  by  the  distraction  of  the 
psychism;  there  are  others  which,  being  true  habits,  that  have  become 
unconscious,  voluntary,  and  automatic,  can  only  disappear  if,  by  the 
intervention  of  his  attention,  the  patient  will  grasp  the  conscious 
mechanism.  Still  further,  we  must  frankly  say  that  under  the  action 
of  the  attention  alone  the  habit  tends  to  disappear  and  be  modified, 
and  behaves,  as  a  matter  of  fact,  like  a  phenomenon  of  normal  auto- 
matism Vv'hich  would  disturb  the  action  of  the  psychism. 

If,  therefore,  a  subject  suffering  from  merycism  will  be  careful  about 
his  regurgitations  after  a  meal  and  will  make  an  effort  to  inhibit  them 
by  his  will,  he  will  succeed  at  first  in  putting  them  off  for  a  time,  and 
finally  in  making  them  disappear  altogether. 

As  for  the  aerophagist,  he  must  be  made  to  understand  how  and 
when  he  swallows  air,  and  asked  to  avoid  all  those  actions  which 
might  lead  to  such  a  result.  There  are  all  sorts  of  classic  proceedings 
to  hold  the  attention  of  the  patients,  such  as  that  which  consists  in 
putting  a  ribbon  tightly  around  the  neck,  which,  because  it  interferes 
slightly  with  swallowing,  reminds  these  patients  of  what  they  ought  to 
avoid,  or  of  placing  a  cork  between  the  teeth,  holding  the  mouth 
slightly  open,  and  thus  hindering  the  swallowing  movement. 

D.  Intestinal  Manifestations  of  Neuropaths:  Diarrhœa  and  Con- 
stipation.— We  shall  say  only  a  few  words  concerning  the  treatment 
of  the  phobias  of  diarrhoea  or  constipation  to  which  general  psycho- 
therapeutic methods  pertain  almost  exclusively.  It  will  be  enough  to 
reassure  these  patients,  and  to  show  them  how  the  interruptions  in  their 
life  are  altogether  out  of  proportion  to  the  accident  itself  which  they 
dread.  One  must  persuade  them  to  assume  an  indifferent  attitude  to 
the  possible  occurrence  of  an  imperative  diarrhœa  or  an  obstinate  con- 
stipation. ''The  only  inconvenience,"  tell  them,  ''will  be  to  change  your 
linen,  or  take  a  purgative,"  but  assure  them  that  there  is  really  no 
reason  whatsoever  for  leading  the  life  of  a  recluse.  One  runs  no  risk 
in  guaranteeing  them  that  the  accident  will  not  occur  again,  for  that  is 
really  in  accord  with  the  truth.  Here,  again,  one  must  use  distraction, 
the  word  being  taken  here  in  its  true  etymological  sense. 

For  the  whole  class  of  educated  constipations  and  diarrhœas  it  is 
evident  that  what  has  been  accomplished  by  education  and  habit  may 
be  undone  by  re-education.    To  persuade  the  latter  to  lengthen  progrès- 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.         331 

sively  the  time  between  their  visits  to  the  toilet,  and  to  induce  the 
former  to  ''meditate"  regularly  and  lengthily  upon  the  result,  con- 
stitutes, as  a  matter  of  fact,  the  whole  therapy  of  these  patients.  But  it 
would  be  illogical  for  the  physician,  as  well  as  the  patient,  to  hope  to 
get  rid,  in  a  few  days,  of  a  symptomatology  which  has  been  increasing 
sometimes  for  years.  Nevertheless,  with  a  little  patience  and  hearty 
endeavor,  there  is  nothing  to  prevent  one  from  obtaining  good  results 
under  all  circumstances. 

The  atonic  constipation  of  those  who  are  extremely  exhausted  by 
insufficient  food  and  emotional  fatigue  carries  with  it  no  psychothera- 
peutic indications,  except  those  which  concern  its  possible  persistence 
after  the  patients  have  recovered  their  general  state  of  health.  This 
phenomenon  is  not  rare,  especially  if  one  permits  such  subjects  to 
form  bad  habits  along  these  lines  while  by  isolation,  rest,  and  overfeed- 
ing one  is  trying  to  bring  them  back  to  their  general  state  of  health. 
One  only  needs  to  be  warned  of  the  danger. 

We  now  come  to  spasmodic  constipation  due  to  mental  representa- 
tion and  the  mucomembranous  enterocolitis  which  is  the  direct  result 
of  it.  This  last  affection  includes  so  many  different  elements  that  it 
is  not  astonishing  that  many  physicians  refuse  to  admit  that  it  may 
be  purely  neuropathic  in  its  origin.  They  do  not  consider  it  possible 
to  cure  it  by  having  recourse  alone  to  psychotherapy  and  re-education. 
This  is  why,  we  think,  it  so  often  happens  that  when  they  do  turn  to 
such  a  therapy  it  is  inefficacious,  because  it  is  incomplete,  and  because 
the  physician  has  not  sufficiently  taken  into  consideration  the  different 
elements  which  start  and  encourage  psychic  fixation. 

The  psychism  of  the  patient  is,  as  a  matter  of  fact,  completely 
centred  upon  his  intestines,  and  the  phenomena  which  recall  either  con- 
tinuously or  intermittently  this  fixation  are  numerous.  Here  one  must 
pay  a  great  deal  of  attention  to  the  morale  of  the  subject,  which  is 
generally  very  bad.  Every  depressing  idea,  by  the  very  force  of  cir- 
cumstances, brings  the  patient's  mind  back  again  to  his  intestines. 
Then,  very  often,  being  put  upon  the  most  extraordinary  diet,  whose 
food  value  is  wholly  insufficient,  these  patients  become  extremely 
emaciated  if  not  cachectic.  Their  strength  is  uncertain,  and  every 
time  that  they  have  any  work  whatever  to  accomplish  their  general 
feeling  of  weakness  which  is  brought  about  directs  their  ideas  to  the 
intestinal  trouble  which  they  hold  responsible  for  it. 

On  the  other  hand,  having  been  thoroughly  educated  by  the  re- 
verse psychotherapy  which  consists  in  teaching  the  patient  to  count 
and  catalogue  his  symptoms,  a  certain  patient  formed  a  habit  of 
watching  himself  and  noticing  particularly  all  his  intestinal  phenom- 
ena. He  would  feel  his  abdomen  and  try  to  place  the  intestines,  and 
look  with  the  most  minute  care  to  see  if  there  was  any  mucus  or  possibly 
some  sign  of  a  false  membrane  in  his  stools. 


332     THE  TREATMENT  OF  PSYCHONEUROSES. 

Having  fixed  ideas  concerning  their  diet,  such  subjects  become  more 
and  more  phobic  concerning  their  food.  Every  dish  which  is  thought 
to  be  dangerous  or  not  properly  prepared  turns  the  patient's  mind 
toward  his  intestines.  Finally  patients  who  have  been  ill  for  months 
and  sometimes  years  find  their  condition  complicated  by  a  whole  series 
of  phenomena  due  to  habit, — educated  constipation,  false  diarrhœa,  with 
tenesmus,  due  to  frequent  visits  to  the  toilet,  etc. 

All  these  phenomena  ought  to  be  carefully  gone  over,  for  they 
furnish  all  the  special  therapeutic  indications.  To  neglect  any  one 
among  them  is  to  run  the  risk  of  set-backs,  whose  frequency,  if  one  is 
not  sufficiently  alert  concerning  them,  seems  to  us  at  present  quite  com- 
prehensible. In  order  to  bring  up  the  general  condition  as  well  as  the 
moral  tone  of  the  subject  by  appropriate  measures,  one  must  not  hesi- 
tate, if  the  case  demands  it,  to  put  the  patient  into  either  comparative 
or  absolute  isolation  on  the  one  hand,  and  to  explain  to  him  the  exact 
nature  of  all  his  symptoms,  and  to  get  him  out  of  the  habit  of  watching 
himself  at  any  time  or  in  any  way  ;\^ and,  on  the  other  hand,  to  re- 
educate the  patient  concerning  his  food  in  the  way  that  we  have  de- 
scribed in  connection  with  the  treatment  of  false  gastropaths;  and 
finally  to  assure  him  that  all  these  phenomena  of  education  and  habit 
will  disappear:  such  are  the  various  elements  of  the  treatment.  The 
cure  will  only  be  obtained  when  the  patient  restored  physically  and 
morally  will  no  longer  think  of  his  intestines,  and  will  no  longer  have 
any  reason  to  think  of  them. 

It  would  be  preposterous  to  think  that  cases  of  long  standing,  com- 
plicated by  an  extremely  strong  systematization  of  multiple  origin, 
could  be  cured  in  a  few  days.  Psychotherapy  can  do  many  things, 
but,  quite  contrary  to  direct  suggestion,  it  does  not  pretend  to  per- 
form miracles,  and  it  will  not  be  rare  for  the  physician  to  ask  a 
patient  to  grant  him  several  weeks,  and  sometimes  three  or  four  months, 
in  order  to  bring  about  an  absolute  and  definite  cure.  The  main  thing 
is  that  the  patient  should  be  warned  of  the  duration  of  his  treatment, 
and  that  he  should  know,  what  is  nothing  more  than  the  truth,  that  his 
cure  will  be  accomplished  in  the  end. 

There  are  some  subjects  who  are  so  slightly  affected  that  a  few  ex- 
planations and  a  few  statements  made  by  a  physician  in  whom  they 
have  placed  their  confidence  are  enough  to  cure  them.  But  it  would  be 
perfect  folly  to  say  to  a  patient  with  an  old  established  enterocolitis, 
''There  is  nothing  the  matter  with  your  intestine,  don't  pay  any  atten- 
tion to  it,"  and  then  be  astonished  to  find  that  he  was  not  cured,  buti 
was  going  about  proclaiming  the  inefficacy  of  psychotherapy,  and  in- 
sisting upon  the  true  organic  nature  of  his  mucomembranous  entero- 
colitis. 

We  have  now  finished  the  particular  therapy  to  be  applied  to  the 
functional  manifestations  that  are  centred  about  the  digestive  tract.    It 


THEEAPY  OF  FUNCTIONAL  MANIFESTATIONS.         333 

is  unquestionably  true  that  a  great  number  of  peculiar  eases  have  been 
left  out  of  our  descriptions,  which  are  of  necessity  rather  schematic; 
this  is  because  in  psychoneurotic  material  the  individual  symptomatic 
variability  is  considerable.  We  think,  nevertheless,  that  we  have  pointed 
out  with  sufficient  clearness  what  are  the  usual  elements  of  treating 
the  psychoneuroses  and  their  functional  manifestations.  They  may  be 
summed  up  as  follows:  General  psychotherapy  of  the  moral  condition 
of  the  subject.  Psychotherapy  of  the  psychic  fixations  by  re-education 
or  by  distraction.^  Psychotherapy  of  disturbance^  due  to  habit  by  the 
voluntary  re-education  of  the  patient,  or  what  we  might  call  auto- 
reeducation.  Improvement,  if  there  is  occasion  for  it,  of  the  general 
condition.  These  four  elements,  which  suppose,  on  the  other  hand,  the 
frequent  intervention  of  the  adjuncts  of  psychotherapy,  will  be  found 
constantly  in  the  therapeutic  studies  which  follow. 

II.  Functional  Manifestations  in  the  Urinary  Apparatus. 

The  floating  kidney  which  is  so  often  found  in  the  course  of  the 
psychoneuroses  as  a  direct  consequence  of  emaciation  would  furnish  no 
other  therapeutic  indications  than  that  of  putting  flesh  upon  the  patient 
if  it  did  not  so  often  become  the  starting-point  of  phobic  phenomena 
and  persistent  pains.  These  last  troubles  only  disappear  when,  under 
psychotherapy,  the  patient  has  grasped  the  true  nature  of  the  symptoms 
of  which  he  complains,  and  when  thus  warned  he  will  consent  to  turn 
his  attention  away  from  them.  We  shall  postpone  the  study  of  the 
processes  by  which  one  can  find  *' distraction  "  from  a  painful  symptom 
until  we  come  to  the  paragraph  devoted  to  the  treatment  of  pains,  and 
shall  now  take  up  modifications  of  urinary  secretion. 

A.  Disturbances  of  the  Urinary  Secretion. — We  have  seen  that  two 
classes  of  persistent  polyuria  exist,  apart  from  accidental  emotional 
polyuria,  which  is  a  common  phenomenon  without  any  therapeutic 
importance.  There  are  polyurias  which  may  be  very  reasonably  ex- 
plained, up  to  a  certain  point,  as  habit,^  or  as  due  to  taking  a  very 
large  amount  of  liquid  daily.  Such  a  polyuria  is  amenable  to  the 
process  of  auto-reeducation.  The  patients  will  progressively  reduce  the 
amount  that  they  drink  until  it  has  become  normal  a^ain.  If  their 
habit  has  been  established  for  some  time,  they  will  often  experience 
considerable  difficulty,  especially  if  this  reduction  is  made  too  rapidly. 
It  will  happen  that  they  will  feel  an  imperative  desire  to  drink,  to 
which  if  they  wish  to  be  cured,  and  to  be  cured  quickly,  they  must  not 
give  in.     In  certain  cases,   and  especially  when  dealing  with  rather 

*The  word  "distraction,"  which  comes  naturally  to  our  pen  during  the  course 
of  this  work,  ought  always  to  be  taken  in  its  true  etymoloorieal  sense, — namely, 
"  All  kinds  of  diversion  which  turn  the  mind  or  the  spirit  to  other  things  " 
(Littré). 


334     THE  TREATMENT  OF  PSYCHONEUROSES. 

weak-willed  people,  it  is  better  to  reduce  very  slowly  the  amount  of 
liquid  swallowed,  and  to  allow  weeks  and  even  months  for  obtaining 
the  cure,  rather  than  to  run  any  risk  of  a  set-back.  It  is  a  very  bad 
system  to  attempt  to  beguile  the  patient's  thirst  by  the  use  of  candy 
drops  or  by  taking  sips  of  some  refreshing  liquid,  etc.  In  this  way  one 
only  fixes  more  decidedly  the  psychic  idea  of  the  need  of  drinking,  an 
idea  to  which  under  such  conditions  the  patient  nearly  always  ends  by 
giving  in. 

It  is  needless  to  say  that  it  will  always  be  necessary  to  explain  to 
the  patient  the  nature  of  his  condition,  and  that,  if  he  can  succeed  by 
various  processes  in  keeping  his  attention  for  a  greater  or  less  length 
of  time  on  something  else,  which  will  make  him  forget  for  a  time  his 
need  of  drinking,  the  most  favorable  psychic  mobilization  will  be 
obtained. 

We  shall  study  the  treatment  of  hysterical  polyurias,  the  second 
class  of  persistent  polyurias,  at  the  same  time  as  that  of  the  symptoms 
which  properly  belong  to  this  psychoneurosis.  To  this  chapter  also  we 
shall  postpone  the  therapeutic  study  of  hysterical  anuria. 

Ischuria  by  adipsia  does  not  need  any  very  long  commentary.  It 
is  a  mental  anorexia  which  refuses  certain  drinks.  Its  treatment,  which 
often  cannot  be  accomplished  except  by  means  of  isolation,  consists  in 
making  the  subject  take  a  normal  amount  of  drink  when  he  is  com- 
manded to  do  so.  If  one  explains  to  the  patient,  at  the  same  time,  the 
origin  of  his  sitiophobia,  one  will  cure  him  rapidly  and  surely. 

B.  Disturbances  of  Urination  or  Micturition.     False  Urinaries. — 

When  one  finds  that  one  has  to  deal  with  a  patient  presenting  a  very 
complete  symptomatology  of  a  false  urinary,  the  situation  is  practically 
the  same  as  that  which  is  offered  by  a  pronounced  enterocolitic.  The 
moral  condition  is  deplorable,  the  psychic  depression  often  very  marked, 
with  considerably  exaggerated  emotionalism,  localized  spasmodic  phe- 
nomena of  the  sphincter  of  the  membranous  urethra,  habit  symptoms, 
increased  frequency  in  particular,  with  or  without  consecutive  poly- 
uria,— all  the  elements,  in  fact,  mutatis  mutandis,  which  we  have  found 
in  the  condition  of  the  enterocolitides  are  found  again  here. 

To  like  symptomatology  is  applied  a  similar  therapy.  It  will  be  neces- 
sary to  concern  one's  self  with  the  moral  condition  of  the  false  urinary, 
to  build  up  his  physical  condition,  to  destroy  the  psychic  fixations  which 
are  the  starting-point  of  his  spasm,  and  to  make  him  lose  by  re-educa- 
tion all  the  bad  habits  which  he  has  formed.  But,  before  anything  else, 
one  must  assure  one's  self  that  the  psychic  fixation  is  not  fostered  by 
any  organic  elements.  A  preliminary  examination  will  be  absolutely 
necessary  for  that.  It  alone  will  permit  one  to  state,  when  knowing 
the  cause,  the  functional  nature  of  the  symptoms  presented.  If  one  is 
not  equipped  for  this  examination,  or  if  one  is  not  perfectly  competent 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.        335 

to  make  this  kind  of  an  exploration,  before  beginning  any  psychic  treat- 
ment one  must  send  the  patient  to  a  specialist,  indicating  to  him  (but 
only  to  him)  the  very  strong  suspicion  that  the  patient  may  be  a  pure 
neuropath.  Before  such  a  local  examination  was  made  it  would  be 
difficult  to  make  the  patient  admit  that  we  had  any  right  to  treat  him 
as  a  nervous  case,  after  so  often  refusing  to  consider  himself  as  such. 
Acting  in  such  a  way,  one  would  lose  his  confidence,  and  as  the  result 
the  psychotherapy  would  have  no  effect.  And  this  would  happen  all 
the  more  because  very  often  the  patient  has  been  before  to  physicians 
w^ho,  although  they  have  examined  him,  have  thought  that  they  ought 
to  treat  him  as  they  would  an  organic,  or  at  least  have  practised  enough 
local  therapy  upon  him  to  confirm  his  fixations.  We  have  seen  only 
too  many  cases  of  this  kind. 

It  goes  without  saying  that,  once  the  neuropathic  nature  of  the 
disturbances  has  been  proved,  there  is  no  place  for  local  therapy,  which 
should  be  rigorously  interdicted.  General  psj^ehic  actions  alone  are 
able  to  exert  favorable  action. 

It  will  sometimes  happen  that  the  persuasive  action  of  the  physician 
is  enough  for  the  patient,  who  after  a  single  conversation  is  convinced 
to  give  up  all  his  pathological  convictions.  It  may  happen  also  that 
the  therapy  may  be  much  more  difficult,  and  that,  to  avoid  pathological 
reorientations  and  recollections  and  memories  of  all  kinds,  one  may  find 
it  advisable  to  prescribe  isolation. 

One  may  meet  all  degrees  between  the  most  characteristic  false 
urinary,  who  is  depressed  and  exhausted,  and  the  patient  who  only 
presents  a  few  functional  troubles,  to  w^hich  he  attaches  a  greater  or 
less  importance. 

Thus,  one  may  meet  subjects  suffering  from  simple  increase  in 
urination,  who,  after  a  few  explanations,  accompanied  by  a  little  advice 
about  allowing  a  greater  length  of  time  between  their  micturitions, 
will  be  rapidly  cured. 

"With  a  single  conversation  also  one  will  be  able  to  cure  women  who 
have  the  idea  that  they  are  suffering  from  an  incontinence  which  is 
partially  true.  It  will  be  enough  to  explain  to  them  how  common  this 
symptom  is,  and  how  wrong  it  is  for  them  to  pay  such  serious  attention 
to  it. 

It  is  simply  a  question  of  re-education,  on  the  other  hand,  to  accom- 
plish the  cure  of  patients  who,  for  one  reason  or  another,  have,  by 
degrees,  more  or  less  completely  inhibited  their  sensation  of  need  for 
urination,  and  who  are  suffering  from  a  relative  retention. 

It  is  quite  a  different  matter  when  one  has  to  do  with  any  kind  of 
pain,  urethral,  vesical,  or  perineal,  which  one  may  find  among  certain 
patients,  and  which  requires  a  very  intense  kind  of  psychotherapy,  with 
recourse  sometimes  to  isolation.  We  shall  refer  to  these  phenomena 
again  when  we  take  up  the  therapeutic  study  of  pains. 


336     THE  TREATMENT  OF  PSYCHONEUROSES. 

Pain  associated  with  frequency  of  micturition  constitutes  false  cystitis, 
and  the  treatment  of  the  latter  ought  to  take  into  consideration  these 
two  elements,  which  are  subjectively  very  closely  allied  one  with  another. 
It  is  impossible  to  reduce  completely  the  frequency  of  micturition  as 
long  as  the  pain  in  the  bladder  has  not  yielded,  and  the  treatment  by 
re-education  of  the  frequent  micturition  cannot  be  carried  on  unless 
the  painful  sensations  can  be  made  to  disappear  simultaneously. 

False  prostatics,  who,  as  a  matter  of  fact,  are  only  patients  with 
phobias  concerning  their  prostates,  whose  psychism  has  too  often  been 
cultivated  by  some  unfortunate  local  therapy,  need  only  to  be  re- 
assured. It  is  necessary  for  the  psychotherapeutic  action  to  be  strong 
enough  for  the  patient  to  cease  concerning  himself  so  much  with  his 
prostate.  It  is  merely  a  question  of  general  psychotherapy,  of  arousing 
the  patient's  energy,  stirring  up  his  feelings,  etc.  This,  moreover,  is 
the  general  therapy  of  all  functional  manifestations,  although,  as 
far  as  the  individual  patient  is  concerned,  there  are  many  special 
indications. 

III.  Functional  Manifestations  in  the  Genital  Apparatus. 

A.  Genital  Troubles  in  Men — The  functional  manifestations  in  the 
genital  apparatus  are  those  that  more  than  any  others  offer  great  diffi- 
culties for  psychotherapeutic  treatment.  There  are  as  many  particular 
cases  as  there  are  patients,  each  one  of  which  requires  appropriate  thera- 
peutic treatment,  and  demands  that  the  physician  should  exercise  all 
the  ingenuity  of  which  he  is  capable.  This  is  because,  instinctive  though 
the  function  may  be,  yet  any  intervention  of  attention  or  emotion  is 
liable  to  change  it,  and  once  the  sexual  function  is  disturbed  it  'prac- 
tically means  that  whenever  it  is  exercised  it  cannot  help  but  recall  the 
emotions  or  states  of  attention  which  existed  previously  and  which  have 
every  chance  to  be  reproduced.  The  custom  of  not  talking  about  sexual 
manifestations  makes  it  almost  impossible  to  discuss  the  subject,  and, 
as  may  easily  be  understood,  it  is  extremely  difficult,  outside  of  a  few 
particular  cases,  to  teach  a  patient  how  to  re-educate  himself.  We  must 
also  add  that  we  have  no  intention  here  of  doing  more  than  indicating 
the  general  rules  by  which  physicians  may  be  guided  in  particular  cases. 

First  of  all,  in  such  patients — whose  moral  condition  is  generally 
deplorable,  more  so  than  perhaps  in  any  other  functional  manifestation 
— general  psychotherapy  of  the  moral  and  mental  condition  is  very 
definitely  indicated.  If,  on  the  other  hand,  one  explains  to  the  patient 
the  exact  nature  of  the  phenomena  which  disturb  him,  and  if  in  this 
manner  one  succeeds  in  reassuring  him,  one  will  evidently  have  accom- 
plished a  very  useful  service.  But  it  is  infinitely  rare  ^that  by  these 
proceedings  alone  one  can  succeed  in  conquering  the  patient's  appre- 
hensions and  the  emotional  phenomena  to  which  they  give  .rise,  and  as 
a  result  the  local  inhibitions  which  follow. 


THERAPY  OF  FUNCTIONAL  IVIANIFESTATIONS.        337 

A  certain  number  of  classes  of  patients  seem  to  us  to  be  established, 
each  one  presenting  several  special  indications. 

The  first  category  consists  of  the  chaste,  who,  by  one  of  the  mechan- 
isms which  we  have  already  studied,  have  become  afflicted  by  sexual 
phobias,  and  imagine  themselves  attacked  by  an  impotence  which  they 
have  never  experienced.  These  patients,  although  their  situation  seems 
so  illogical,  are  extremely  numerous.  Their  condition  usually  arises 
from  a  conflict  which  exists  in  them  between  the  sexual  instincts  which 
make  themselves  felt,  and  certain  scruples  which,  make  them  consider 
not  only  the  thing  itself  but  even  the  idea  as  shameful  and  blameworthy. 
Being  obsessed  with  sexual  phobia  on  the  one  hand,  these  patients,  on 
the  other  hand,  by  reason  of  the  multiplicity  of  sexual  representations 
which  throng  their  mind,  frequently  experience  repeated  seminal  losses. 

If  the  patient  under  consideration  is  old  enough,  after  having  re- 
assured him,  one  ought  to  advise  him  to  marry.  In  marriage,  as  a 
matter  of  fact,  the  sexual  excitement  may  be  satisfied  and  quieted  down 
without  raising  any  scruples.  On  the  other  hand,  it  is  very  comforting 
for  the  sexual  phobic  to  feel  himself  in  the  presence  of  a  partner  whom 
he  knows,  or  at  least  believes,  to  be  very  ignorant  concerning  matters 
of  the  sexual  life,  and  incapable  of  judging  weaknesses  which  under 
these  conditions,  however,  one  might  almost  say  never  occur. 

If,  for  reasons  of  position  or  youth,  marriage  is  impossible  or  must 
be  too  indefinitely  postponed,  the  task  of  the  physician  becomes  much 
more  delicate.  The  question  will  naturally  be  raised  whether  one  is 
right  under  such  circumstances  to  advise  a  young  man  to  avail  himself 
of  professional  amours.  From  the  point  of  view  of  pure  morality  it 
is  quite  certain  that  such  conduct  could  not  be  defended.  But  what  we 
also  believe  is  this,  that,  still  remaining  within  the  medical  domain, 
such  indications  would  only  offer  dangers  of  various  kinds.  Suppose 
even  that  it  was  a  choice  of  running  one  or  the  other  **risk,"  there 
would  be  not  the  slightest  doubt  that  one  would  eventually  find  the 
patient  uneasy  and  overcome  with  scruples,  reproaching  himself  over 
the  act  which  he  had  committed  and  which  he  considers  degrading  and 
immoral.  He  would  once  more  become  chaste,  but  chaste  through  dis- 
gust, and  not  through  principle.  His  moral  condition,  on  the  contrary, 
would  be  in  no  way  improved.  On  the  other  hand,  if  it  is  usual  for  the 
sexual  imagination  of  the  chaste  to  be  singularly  exaggerated,  it  is  also 
true  that,  more  especially  on  account  of  their  being  capable  of  very 
definite  images,  the  imagination  of  the  ** initiated"  chaste  is  passionate 
in  the  extreme. 

"What  then  is  to  be  done?  It  would  seem  to  us  that  the  best  way 
to  act,  in  connection  with  such  a  patient,  is  to  make  him  thoroughly 
understand  all  the  phenomena  which  concern  the  sexual  life,  and  to 
let  him  know  that  the  disturbances  which  he  feels  result  from  errors  of 
interpretation,  and  that,  as  a  matter  of  fact,  he  is  experiencing  per- 
fectly natural  physiological  phenomena,  over  which  he  has  no  need  to 
22 


338     THE  TREATMENT  OF  PSTCHONEUROSES. 

be  disturbed,  and  concerning  which  he  has  no  right  to  reproach  him- 
self. One  must  make  the  patient  grasp  the  fact  that  his  dreams  and 
his  imaginations  torment  morally,  and  that  it  is  they  which  have  drawn 
him  into  his  obsessions  and  sexual  phobias;  one  must  also  make  him 
realize,  we  insist,  that,  although  man  is  nearly  always  master  of  his 
actions,  he  is  by  no  means  master,  in  the  same  degree,  of  ideas  which 
may  invade  his  field  of  consciousness,  and  which  proceed  from  the 
psychological  automatism.  One  must  then,  in  fact,  turn  one's  attention 
chiefly  to  the  moral  condition,  to  reassure  and  tranquillize,  and  to  turn 
away  from  the  sexual  sphere  the  attention  which  scruples,  reproaches, 
and  uneasiness  have  brought  to  bear  upon  it.  If  the  patient  has  seminal 
losses,  one  must  prove  to  him  that  in  continent  men  this  is  a  normal 
phenomenon,  and  that  the  exaggeration  of  this  may  be  due  exclusively 
to  the  introduction  into  his  conscience  of  too  many  mental  representa- 
tions of  a  sexual  nature,  which  of  themselves  give  rise  to  that  feeling  of 
scruple  which  he  is  nursing  in  his  mind. 

On  the  whole,  it  would  be  much  better  to  advise  him  to  remain 
chaste  until  the  day  when  he  can  satisfy  his  needs  in  a  legitimate 
way. 

In  the  same  class  of  subjects  one  also  finds  patients  who  are  afflicted 
in  a  very  peculiar  way,  and  who  on  the  contrary  complain  of  being" 
cold,  and  of  not  experiencing  any  of  the  physical  manifestations  of  the 
sexual  instinct.  This  physical  frigidity  is  quite  often  complicated  by  a 
very  marked  psychic  excitation. 

In  this  class  of  patients  there  are  some  who  are  chaste  only  because 
their  first — and  consequently  their  last — attempts  were  wholly  negative 
in  results.  Here  again  one  must  make  a  distinction.  There  is  a  whole 
series  of  patients  whose  sexual  affection  is,  as  a  matter  of  fact,  con- 
stitutional, who  are  major  psychasthenics,  sexual  inverts  who  may  or 
not,  at  the  time  when  one  sees  them,  be  still  unaware  of  their  own 
state.  Such  patients  are  mental  cases,  and,  if  they  are  capable  of 
secondary  psychoneuroses,  a  real  mental  disturbance  or  degenerative 
disturbance  of  a  quasi-organic  nature  is  at  the  bottom  of  things.  The 
prognosis  of  such  is  not  at  all  apt  to  be  good,  and  the  therapy  is  too 
often  deficient.  The  psychic  and  moral  education  of  the  subject  must 
be  taken  up,  for  there  is  a  whole  psychological  domain  lacking,  which  one 
must  endeavor  to  recreate.  It  sometimes  happens  that  one  is  obliged  to 
ask  these  patients  to  accept  their  frigidity,  and  completely  and  definitely 
to  renounce  all  sexual  life.  But  to  counsel  such  to  marry  would  be  to 
court  disaster.  If,  at  the  end  of  a  very  long  psychical  reeducation 
whose  effects  are  expressed  by  the  appearance  of  physical  and  psycho- 
physical phenomena  so  that  one  might  consider  them  cured,  we  think 
that  in  the  case  of  these  subjects,  but  these  subjects  only,  an  *' experi- 
ment'*  might  be  attempted  before  marriage. 

Along  with  these  who  are  naturally  frigid  there  are  others  who  are 
frigid  by  persuasion.     These  are  subjects  who,  by  religious,  moral,  or 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.        339 

philosophical  conviction,  have  been  turned  away  in  a  very  decided  manner 
from  the  sexual  life.  They  are  those  who  have  too  assiduously  read 
the  ''Kreutzer  Sonata/'  who  have  become,  if  one  might  so  express  it, 
regular  sexual  anorexics.  Let  them  in  some  particular  instance,  or  in 
general,  experience  the  desire  of  living  the  sexual  life  again,  and  they 
are  obliged  to  admit  that  it  is  somewhat  late,  and  that  the  psycho- 
physical associations  are  broken.  Intense  obsessions  then  arise.  The 
patient  runs  from  one  professional  to  another,  risks  the  most  hazardous 
practices,  without  any  other  result  than  that  of  becoming  morally 
depressed. 

It  is  seldom  that  a  little  reasoning,  moral  rest,  and  the  abandoning 
of  any  new  attempts  does  not  lead  to  a  cure.  For  such  patients  marriage 
is  also  a  solution,  but  at  a  period  which  must  be  a  little  more  remote 
than  for  the  subject  which  we  have  just  been  considering. 

A  second  large  class  of  facts  include  all  cases  of  accidental  im- 
potence. By  one  of  the  mechanisms  which  we  have  studied  in  the  first 
part  of  our  work,  subjects  who  have  hitherto  been  normal  become  abso- 
lutely— or  rather,  if  we  might  say  so,  comparatively — incapable  of  prac- 
tising the  sexual  act.  This  is  because,  as  a  general  rule,  all  the  psychic 
phenomena  which  intervene  in  the  course  of  the  sexual  act  tend  to 
excite  it;  but  in  these  people  psychological  or  emotional  disturbances 
come  in  to  interfere  and  exert  an  inhibiting  influence.  As  a  rale,  in 
fact,  all  the  ideas  which  may  be  associated  with  the  sexual  act  do  not 
belong  to  the  act  in  itself,  but  to  its  ulterior  purposes,  its  causes,  or  its 
better  utilization.  A  man  in  the  act  of  coitus  will  think  of  his  pleasure 
or  the  ultimate  consequences  of  it.  If  he  thinks  of  his  erection  it  will 
be  in  a  purely  objective  manner,  and  not,  as  the  patient  does,  in  a 
questioning  manner.  The  individual,  in  fact,  who  can  be  obsessed,  and 
who  accidentally,  from  some  emotional  cause,  has  found  himself  unable 
to  complete  the  act,  or  the  man  w^ho  in  some  way  has  been  made  im- 
potent by  distraction,  each  time  that  he  practices  coitus  in  the  future 
will  find  awakened  in  him,  accompanied  by  a  very  marked  emotional 
state,  a  dubious  questioning  over  the  very  possibility  of  this  coitus. 
The  subjective  fear  of  trouble  is  rapidly  translated  into  an  objective 
weakness.    And  again  he  will  fail  to  get  his  orgasm. 

To  illustrate  the  therapeutic  point  of  view,  I  will  describe  three 
types  of  cases,  which  require  very  different  handling,  in  order  to  obtain 
the  necessary  and  satisfactory  condition  to  treatment, — viz.,  re-ediica- 
tian  and  distraction. 

It  is  necessary  to  get  the  patient  in  some  way  or  other  to  turn  his 
attention  away  from  the  manner  in  which  he  is  conducting  himself 
while  he  is  practising  coitus,  or  else  not  to  be  disturbed  by  it. 

First  case:  The  patient  is  a  celibate  but  marriageable. 

Here  the  course  to  pursue  is  very  simple.  One  should  advise  him 
to  marry  some  one  very  young,  where  the  ignorance  of  his  companion 
would  offer,  as  in  the  case  of  the  chaste  man  of  w^hom  we  have  just 


340      THE  TREATMENT  OF  PSYCHONEUROSES. 

spoken,  the  best  element  of  security.  It  may  happen  sometimes  that 
the  patient's  first  attempts  are  not  wholly  successful,  but,  as  there  is 
no  occasion  to  hurry,  and  as  with  a  modest  and  innocent  virgin  mascu- 
line pride  has  nothing  to  suffer  from  a  failure  which,  if  it  occurs, 
will  remain  a  secret,  matters  generally  end  by  arranging  themselves. 
But,  on  the  other  hand,  marriage  with  a  widow  should  not  be  advised. 

Second  case:  The  subject  is  married,  and  he  is  unable  to  play  the 
part  of  a  husband. 

It  is  first  necessary  to  inquire  into  the  conditions  which  preside 
over  the  psychic  feeling,  or  the  emotional  inhibition.  Then  one  re- 
assures the  patient,  and  begs  him  before  submitting  to  any  treatment 
to  bring  his  wife  with  him.  It  is  she  who  in  the  treatment  must  play 
the  principal  rôle.  She  must  arrange  to  stimulate  him  to  desire  her, 
under  such  conditions  that  the  coitus  would  be  quite  unexpected,  and 
in  consequence  there  would  be  no  apprehension  previous  to  the  act 
itself.  In  order  to  make  this  possible,  one  must  prescribe  a  certain 
period  of  complete  abstinence,  during  which  time  the  obsession  will 
have  had  better  chance  to  quiet  down,  as  it  will  not  have  been  kept  in 
mind  by  repeated  failures.  'This  naturally  is  the  only  way  in  which  an 
unexpected  coitus  could  be  accomplished.  On  the  other  hand,  in  every 
way  that  it  is  possible,  all  external  circumstances  which  are  likely  to 
recall  the  emotional  idea  must  be  changed.  A  coitus  which,  for  example, 
cannot  be  stimulated  or  accomplished  successfully  in  the  conjugal 
chamber  or  in  the  light  may  succeed  if  it  is  attempted  in  the  dark,  or 
in  another  room,  or  in  another  house. 

One  can  see  that  the  key  to  therapeutic  success  lies  entirely  in  a 
complete  analysis  of  the  causes  of  the  functional  phenomenon,  and  that 
with  the  help  of  the  wife  one  can  succeed  in  suppressing  the  majority 
of  the  causes,  and  therefore  the  majority  of  the  effects.  Once  a  favor- 
able result  has  been  obtained,  and  the  husband  has  regained  his  com- 
petence and  self-respect,  the  cure  may  be  considered  as  definite. 

Third  case  :  Here  we  have  a  celibate,  or  a  married  man  who  deceives 
his  wife,  and  who  cannot  present  his  companion. 

One  may  then  avail  one's  self  of  various  proceedings  which  some- 
times one  is  led  to  use  successively  on  the  same  subject.  According  to 
the  degree  of  the  phobia  and  sexual  obsessions  it  will  be  best,  first  of 
all,  for  this  is  the  simplest  measure,  to  try  the  effect  of  simple  abstinence 
during  a  greater  or  less  length  of  time.  If  the  subject  is  very  much 
affected,  the  duration  of  this  abstinence  may  be  prolonged  for  two  or 
three  months.  It  frequently  happens  that,  during  a  period  as  long  as 
this,  forgetfulness  occurs,  and  the  patient  recovers  the  integrity  of  his 
sexual  functions. 

It  will  sometimes  happen,  however,  that  one  can  cure  the  patient 
psychically,  by  convincing  him,  for  example,  of  what  may  be  quite  true, 
— ^viz.,  that  his  impotence  may  be  a  proof  of  the  strength  of  his  love. 
Armed  with  this  doctrine,  which  he  will  develop  to  suit  his  own  needs, 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.  341 

he  may  acquire  an  idea  concerning  his  impotence  which  is  comforting  and 
flattering  to  his  pride,  and  almost  immediately  obtain  favorable  results. 
But  one  must  be  assured  that  he  will  be  illogical  enough  not  to  draw  this 
conclusion,  however  correct,  that  this  love  has  diminished  because  of  it. 

Under  other  circumstances  one  may  be  led  to  give  the  patient  ad- 
vice, the  ethics  of  which  may  be  questionable,  but  which  is  sometimes 
imposed  by  the  situation.  One  might  ask  him  to  change  his  companion, 
and  to  provide  himself,  if  possible,  with  a  transient  partner.  It  is  not 
rare  to  find  that  the  feeling  of  security  springs  up  in  the  presence  of 
a  professional,  to  whom  the  patient  is  quite  indifferent  sentimentally, 
and  who,  on  the  other  hand, — and  this  should  be  carefully  explained  to 
him, — is  not  likely  to  wound  his  masculine  pride.  The  patient  with  his 
self-confidence  restored  may  then  return  to  his  usual  customs. 

Finally,  and  although  as  a  matter  of  principle  the  method  seems 
harmful  to  us,  there  are  nevertheless  cases  where  one  must  have  recourse 
to  indirect  suggestion.  One  could  even  be  led  to  recommend  the 
patient  to  take  various  treatments,  of  which  the  suggestive  action  would 
be  enough,  always,  however,  w^ith  this  condition,  that  during  the  course 
of  the  treatment  abstinence  should  be  maintained. 

We  have  glanced  at  several  kinds  of  cases  which  the  physician  may 
be  apt  to  meet.  We  have  by  no  means  taken  up  all  of  them.  Here, 
for  example,  is  an  old  man  whose  sexual  weaknesses  may  easily  be 
interpreted  as  due  to  senile  involution.  It  is  very  evident  that  this 
situation  demands  special  indications.  It  will  be  necessary  to  make  the 
patient  understand  that  at  his  age  continence  is  the  rule.  But,  if  when 
first  seen  the  patient  is  very  strongly  obsessed  about  his  sexual  desires, 
it  will  not  always  be  quite  prudent  to  ask  him  definitely  to  renounce 
their  indulgence.  For  the  moment  his  personality  is  tremendously 
bound  up  in  his  sexual  functions,  and  ^e  may  run  the  risk  of  bringing 
on  a  very  profound  state  of  depression  if  one  gives  him  any  idea  of 
the  necessary  and  complete  abandonment  of  what  seems  to  him  one  of 
the  vital  elements  of  his  existence.  The  tactful  psychotherapeutist  will 
take  such  steps  that,  first  counselling  a  slight  abstinence,  he  will  profit 
by  this  period  to  modify  progressively  his  patient's  mentality.  He  will 
speak  of  the  physical,  moral,  and  material  dangers  of  senile  amours,  so 
persuasively  that  the  idea  of  definite  continence  instead  of  transitory 
abstinence  will  finally  be  grasped  by  him. 

Let  us  suppose,  again,  the  case  of  a  subject  in  whom  partial  im- 
potence, such,  for  instance,  as  tardy  ejaculation,  has  been  the  result  of 
Malthusian  practices.  It  is  very  certain  that,  before  any  treatment 
is  undertaken,  one  must  disabuse  the  patient's  mind  of  the  ideas  which 
he  holds,  for  if  he  persists  in  them  his  functional  disturbances  will 
become  permanent. 

Then  there  are  subjects  who,  without  being  impotent, — and  the  ease 
is  frequent  among  neurasthenics  with  otherwise  diffused  symptoms, — 
have  a  too  rapid  ejaculation.     In  such  cases  one  c.an  teach  them  to 


342      THE  TREATMENT  OF  PSYCHONEUROSES. 

re-educate  themselves  by  advising  them  to  practise  intermittent  coitus, 
in  which  the  prolongation  of  the  pleasure  will  form  the  surprise. 

Finally,  there  are  other  patients  whose  position  is  peculiarly  lament- 
able. These  are  the  degenerates  with  slowly  developing  symptoms,  in 
whom,  whether  accompanied  or  not  by  sexual  perversions,  impotence 
has  become  established.  When  obliged  to  deal  with  such  patients,  the 
physician  is  helpless.  He  can  hardly  do  more  than  be  profuse  in  his 
consolations,  and  try  to  get  them  to  accept  what  cannot  be  cured.  It 
is  very  rare,  moreover,  that  such  subjects  do  not  have  mental  dis- 
turbances of  all  kinds  arising  to  complicate  the  situation.  Such  patients, 
who  are  ill  mentally,  but  who  are  not  afflicted  with  a  psychoneurosis, 
have,  however,  nothing  to  do  with  our  classification,  except  as  we  have 
indicated. 

In  a  general  way  the  psychotherapy  of  sexual  manifestations  in 
men  is  beset  with  difficulties  in  its  special  applications.  But  it  has 
always  seemed  to  us  that  the  best  chance  for  obtaining  good  results  lay 
in  interesting  one's  self  especially  in  the  patient's  mental  and  still 
more  in  his  moral  condition.  It  is  principally  due  to  the  lack  of  this 
part  of  the  treatment .  that  one  must  attribute  the  set-backs,  which, 
however,  taking  it  all  in  all,  occur  but  rarely,  when  one  knows  how  to 
take  all  the  special  aspects  of  these  manifestations  into  consideration 
along  with  their  very  general  conditions. 

B,  Sexual  M-anifestations  of  Women. — Here  the  mechanisms  are 
not  so  various.  While  the  sexual  manifestations  of  women  are  not 
expressed  by  any  objective  phenomenon,  they  are  much  more  likely  than 
those  of  man  to  yield  to  general  psychotherapy.  It  is  none  the  less  true, 
that,  in  order  to  comprehend  clearly  the  therapeutic  processes  to  be 
applied  to  them,  we  shall  be  obliged  again  to  glance  at  a  certain 
number  of  particular  cases. 

There  is  no  doubt  whatever  that  there  exist  a  certain  number  of 
young  girls  who  are  haunted  by  the  idea  of  the  sexual  act,  that  there 
are  others  who  reproach  themselves  violently  in  a  way  that  amounts  to 
an  obsession  over  the  voluptuous  satisfaction  which  they  have  been  able 
to  obtain  artificially.  But  these  troubles  are  much  more  usually  cared 
for  by  the  confessor  than  by  the  physician.  Nevertheless,  they  some- 
times turn  to  the  physician,  who  under  such  circumstances  has  only  one 
course  to  pursue, — ^namely,  to  advise  them  to  marry  as  soon  as  possible. 

The  physician  is  much  more  often  consulted  for  all  those  phenom- 
ena which  either  closely  or  remotely  bear  upon  vaginismus.  Here  the 
therapeutic  indications,  while  being  very  definite,  are  of  various  kinds. 
The  first  thing  that  is  necessary  to  do  by  direct  psychotherapeutic  action 
is  to  struggle  against  all  the  fears  with  which  the  patient  is  afflicted. 
Without  being  too  afraid  to  shock  her  delicacy,  one  must  explain  clearly, 
and  if  necessary  anatomically,  to  the  patient  just  what  the  sexual  act 
consists  of,  and  make  her  understand  that  there  is  no  reason  why  she, 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.        343 

more  than  any  other  woman,  should  not  lend  herself  to  it.  On  the 
other  hand,  according  to  the  peculiar  mental  condition  of  the  patient, 
there  would  be  an  opportunity  of  awakening  the  sexual  desire  in  her 
by  telling  her  that  the  sexual  act  is  the  very  condition  of  maternity; 
under  other  circumstances,  on  the  contrary,  where  the  vaginismus  is 
due  to  the  fear  of  fecundation,  one  must  attack  the  phenomenon  by 
making  the  woman  understand  how  necessary  maternity  is  to  her 
future  physical  as  well  as  her  future  material  and  moral  benefit.  Finally, 
as  is  the  case  where  the  vaginismus  is  due  to  too  marked  sexual  excita- 
tion and  to  too  vivid  mental  representations,  the  rôle  of  the  psycho- 
therapeutist  will  be  sometimes  to  morally  and  psychically  inhibit  an 
excessive  sexuality. 

A  second  series  of  indications  concerns  the  husband,  whose  clumsi- 
ness or  brutality  may  have  been  the  starting-point  of  the  functional 
manifestations  observed.  Sometimes  it  will  happen  that  the  best  treat- 
ment for  vaginismus  consists  in  educating  the  husband,  and  in  caution- 
ing him  to  be  more  patient.  The  wife,  knowing  that  she  will  not  have 
to  dread  the  rather  rude  treatment  which  had  made  her  suffer  in  the 
sexual  act,  will  lose  her  fear  and  with  it  the  vaginismus  itself.  Many 
women  owe  their  vaginismus  solely  to  a  mismanaged  wedding  iiight. 

In  the  case  of  a  patient  being  extremely  phobic,  with  a  distinct 
fixation  on  her  sexual  organs,  it  may  perhaps  be  wise  to  advise  her  to 
remain  continent  for  a  time,  sometimes  as  long  as  the  period  which  one 
would  prescribe  for  a  man  afflicted  with  functional  sexual  manifesta- 
tions. Before  permitting  her  to  attempt  any  new  experiences,  one  ought 
to  allow  her  time  to  recover  from  those  which  previously  had  had  such 
unfortunate  consequences. 

At  other  times,  and  one  of  us  has,  as  a  matter  of  fact,  observed 
numerous  examples  of  this,  vaginismus  is  the  consequence  of  incom- 
plete coitus.  Either  from  the  beginning  of  marriage,  which  is  rather 
unusual,  or,  as  is  ordinarily  the  case,  after  the  birth  of  the  number  of 
children  that  the  couple  have  desired  to  have,  they  practise  incomplete 
coitus.  There  is  no  longer  any  synchronism  in  the  voluptuous  sensa- 
tions. The  wife,  obsessed  with  the  fear  of  a  pregnancy,  will  not 
abandon  herself  to  pleasure  as  before;  she  waits,  and  watches  for  the 
moment  which  is  supreme  in  her  husband.  The  latter,  on  his  side, 
doing  the  same  thing,  generally  withdraws  before  he  and  his  wife  have 
experienced  their  pleasure,  and  the  ejaculation  takes  place  outside  of 
the  genitals.  The  only  therapeutic  measure  here  of  any  value  is  to 
give  over  such  practices,  which  for  the  man  himself  are  far  from  being 
free  from  danger,  so  true  is  it  that  one  must  never  transgress  the  laws 
of  nature. 

Finally,  there  are  cases  where  it  is  necessary  to  undertake  the  actual 
objective  re-education  of  the  patient,  where  it  is  necessary  to  dilate  the 
vagina,  by  making  her  introduce  into  it  bougies  or  sounds  of  increas- 
ing size,  until  she  is  quite  convinced  that  it  shows  sufficient  receptivity 


344      THE  TREATMENT  OF  PSYCHONEUROSES. 

for  the  act  for  which  it  was  intended.  This  method  has  given  success 
in  eases  of  very  long  standing. 

There  are,  however,  women  in  whom  everything  fails, — direct  psycho- 
therapeutic action,  prolonged  abstinence,  and  progressive  dilation.  This 
is  when  it  is  a  question  of  vaginal  pain,  which  is  entirely  subjective 
and  profoundly  fixed,  for  which  the  therapy  must  be  the  same  as  for 
the  general  treatment  of  all  the  algias.  But  these  cases  are  exceptional, 
and,  whether  isolated  or  associated,  the  different  processes  which  we 
have  just  mentioned  are  almost  always  able  to  re-establish  things  in  their 
regular  way. 

The  contraction  of  the  adductors,  if  it  seems  to  be  permanent,  forms 
an  hysterical  manifestation  amenable  to  general  treatment  of  this  very 
peculiar  kind  of  functional  disturbance.  If,  on  the  other  hand,  it  is 
only  an  accidental  diffusion  of  vaginismus,  it  yields  at  the  same  time  as 
the  latter  to  the  same  therapeutic  intervention. 

We  have  now  come  to  the  very  special  difficulty  which  is  constituted 
by  female  frigidity.  A  certain  number  of  causes  may  create  it.  It 
may  happen  that  it  is  purely  relative,  and  that  only  the  husband  is  to 
blame.  And  if,  under  these  conditions,  the  synchronism  of  voluptuous 
sexual  sensations  is  disturbed,  it  is  not  because  the  woman  is  slower  or 
tardy  ;  it  is  because  the  man  is  too  quick,  if  we  might  use  this  comparison. 
It  is  very  evident  that  under  these  conditions  it  is  the  one  at  fault 
who  should  be  advised,  while  at  the  same  time  the  innocent  one  should 
be  reassured.  More  often  female  frigidity  results  from  all  kinds  of 
inhibitions,  moral  or  religious  scruples,  fear  of  fecundation,  etc.  The 
rôle  of  the  physician  in  these  cases  does  not  need  to  go  any  further  than 
to  calm  fears  which  have  no  grounds,  or  fears  which  they  hesitate  to 
express. 

On  the  other  hand,  one  should  realize  that  in  women  the  voluptuous 
phenomena  are  susceptible  of  much  greater  development  than  in  men. 
There  are  women, — a  very  small  number,  however, — for  whom  educa- 
tion in  this  matter  accomplishes  nothing,  and  who  pass  their  whole 
life  without  realizing  any  sexual  pleasure,  or  without  even  being  dis- 
turbed by  the  fact.  There  are  many  others  in  whom  the  pains  of 
defloration  prevent  and  inhibit  any  voluptuous  sensations.  It  is  then 
not  until  after  a  greater  or  less  length  of  experience  that  the  woman 
learns  to  share  the  sexual  pleasure.  Such  a  phenomenon,  which  is  in 
fact  subnormal,  ought  not  to  be  considered  as  a  pathological  phenomenon. 
When  dealing  with  such  cases,  the  physician  must  be  content  to  reassure 
a  husband  who  is  disturbed,  or  a  woman  who  has  hitherto  been  un- 
moved except  by  the  sorry  expression  of  her  husband  on  seeing  her 
accept  passively  the  passion  which  she  does  not  share.  It  happens, 
nevertheless,  as  we  have  seen,  that  by  a  mechanism  of  this  kind  a  lasting 
frigidity  is  often  established.  It  is  the  very  desire  for  voluptuous 
sensations  which  have  hitherto  not  been  experienced  which  prevents  this 
kind  of  sensation  from  being  produced.     The  wife,  hurt  by  her  hus- 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.        345 

band's  reproaches,  feels  that  she  must  be  lacking  in  sensation,  and 
imagines  that  she  is  abnormal  or  badly  formed,  and  at  each  new  sexual 
relation  there  springs  up  a  new  emotional  state  which  is  peculiarly 
inhibitive.  If  the  physician  is  consulted  in  time,  he  may,  by  pointing 
out  a  healthier  point  of  view,  re-establish  conjugal  harmony,  which 
sooner  or  later  will  satisfy  their  sexual  relations  with  the  voluptuous 
feelings  which  belong  to  it.  Here  medical  intervention  is  prophylactic 
rather  than  curative,  since  they  ask  the  physician  to  make  a  phenom- 
enon appear  whose  absence  is  at  the  time  quasi-normal.  But  the  lack 
of  medical  intervention,  or  any  ill-advised  direction  upon  his  part, 
would  cause  a  state  which  was  only  temporary  to  become  lasting.  When 
the  disturbance  has  been  established  for  a  long  time,  its  therapy  is 
much  more  difficult,  and  here  again,  as  in  the  case  of  men,  it  may 
happen  that  one  can  get  results  from  an  indirect  suggestion  where  psycho- 
therapeutic action  of  the  most  persuasive  kind  would  remain  wholly 
inefficacious. 

As  a  matter  of  fact,  and  to  analyze  things  thoroughly,  women  are 
much  less  apt  than  men  to  have  what  might  properly  be  called  sexual 
fixations  ;  but  what  is  much  more  apt  to  happen  to  her  than  to  him  are 
states  of  moral  depression  and  serious  neurasthenia,  of  which  the 
starting-point  is  of  sexual  origin.  Reproaches,  remorse,  regrets,  im- 
pressions of  some  special  failure,  affecting  by  means  of  sex  the  vast 
domains  of  sentimentality  which  are  so  often  excited  in  women, — these 
are  enough,  if  the  mechanism  of  preoccupations  continues  to  give  rise 
to  serious  neurasthenic  conditions  whose  origin  one  must  know  how  to 
trace  out.  But  then  the  therapy  is  of  a  general  order,  and  does  not  draw 
any  special  indications  from  the  special  origin  of  the  troubles  presented. 

It  happens  very  commonly  that  functional  disturbances  of  a  sexual 
nature  are  passed  on  from  one  of  the  couple  to  the  other.  If  sterility 
be  the  cause,  so  that  thé  disharmony  of  the  sexual  act  becomes  for  both 
the  occasion  for  reciprocal  reproaches,  for  it  may  happen  that  each  one 
of  them  assumes  or  refuses  to  assume  the  entire  responsibility,  the  whole 
conjugal  sexual  life,  encumbered  by  auto-  and  hetero-observation,  may 
be  peculiarly  disturbed  by  it. 

The  intervention  of  the  physician  would  be  of  benefit  if  he  could 
explain,  direct,  and  arrange  matters  ;  but  there  is  no  need  to  dwell  upon 
this.  All  this  therapy  for  sexual  functional  disturbances  may  seem 
rather  delicate.  It  is,  nevertheless,  indispensable  to  know  it,  partly 
on  account  of  the  frequency  of  such  symptoms,  as  well  as  the  difficulty 
which  one  has  in  curing  them  if  one  is  only  half  aware  of  them. 

We  feel  that  we  have  only  given  a  few  rules  which  point  to  the 
paths  which  must  be  followed  in  the  treatment  of  these  patients,  who 
are  often  so  unhappy,  so  obsessed,  so  ashamed  and  depressed,  that  more 
than  one  will  not  hesitate  to  escape  by  means  of  suicide,  from  an  ex- 
istence which  such  troubles  make  unbearable.  There  is,  therefore,  no 
place  for  ridicule  or  irony  in  the  treatment  of  sexual  functional  dis- 


346      THE  TREATMENT  OF  PSYCHONEUROSES. 

turbances,  however  Rabelaisian  they  may  sometimes  be.  One  must  look 
upon  them  as  exceedingly  serious,  and  often  very  grave  conditions, 
because  the  very  life  of  the  patient  may  depend  upon  their  persistence 
or  their  disappearance. 

In  the  treatment  of  a  false  genital  fixation  it  is  very  essential,  how- 
ever material  may  be  the  nature  of  the  phenomena  that  are  met  with, 
not  to  make  fun  of  them.  If  in  a  theoretical  description  one  may  be 
justified  in  using  circumlocution,  with  the  patient  one  must  use  the 
right  word,  the  physiological  or  anatomical  term.  He  must  be  made  to 
understand  that  the  sexual  functions,  for  a  physician  at  least,  are  noth- 
ing to  be  ashamed  of,  or  nothing  to  joke  about.  And  if  it  sometimes 
happens  that  the  patient  jokes  about  his  own  symptoms,  do  not  follow 
him  in  this  line.  He  laughs  perhaps  because  he  thinks  "that  it  is  manly 
to  laugh,"  while  all  the  time  he  is  much  more  inclined  to  weep. 

C.  Gynaecological  Pseudo-manifestations  do  not  offer  any  special 
therapeutic  indications.  The  physician's  chief  work  consists  in  stating 
to  the  patient,  after  a  sufficiently  thorough  examination,  that  she  is 
perfectly  healthy,  in  reassuring  her  concerning  each  of  the  special 
manifestations  which  she  presents,  in  getting  her  to  turn  her  attention 
away  from  her  genital  organs,  and  in  insisting  that  she  give  up  all 
treatment  and  stop  watching  herself.  This  is  very  simple  theoretically, 
but  it  often  runs  up  against  a  most  firmly  established  systematization 
which  has  been  encouraged  and  developed  by  a  long-drawn-out  local 
therapy.  It  is  not  a  rare  thing,  under  these  conditions,  for  the 
neurologist  to  be  obliged  to  call  in  the  help  of  a  gynaecologist,  who  in 
his  turn  tells  the  patient  that  her  fears  are  foolish  and  there  is  no 
necessity  for  treatment.  The  successive  convictions  which  one  thus  tries 
to  implant  in  the  mind  are  not  only  added  to  one  another  but  become 
multiplied,  giving  the  patient  a  feeling  of  perfect  security,  which  per- 
mits her  to  do,  what  is  the  one  thing  that  one  is  trying  to  accomplish, 
— namely,  to  forget  the  functional  manifestations  with  which  she  has 
been  afflicted  and  the  phobias  which  have  deceived  her. 

To  speak  frankly,  these  manifestations  require  a  certain  therapy, 
but  this  therapy  is  prophylactic,  and  to  be  addressed  to  physicians  and 
not  to  patients.  It  is  not  that  we  wish  to  deny  the  value  of  certain 
conservative  practices  in  gynaecology.  But  for  a  certain  number  of  cases 
where  pessaries,  tampons,  glycerin,  ichthyol,  etc.,  are  found  to  be  of 
value,  how  many  others  are  there  where  the  physician  knows  perfectly 
well  that  his  patient  is  in  good  health,  nevertheless  believes  it  to  be 
right,  in  order  to  satisfy  her,  to  make  her  undergo  a  more  or  less 
lengthy  treatment.  He  thinks  that  it  will  calm  her,  but  he  only  ex- 
asperates her.  She  was  merely  nervous,  but  she  becomes  a  neuropath, 
with  fixed  obsessions  concerning  her  genital  organs.  The  physician  is 
responsible  if  he  has  been  weak  enough  to  look  at  things  from  the 
patient's  point  of  view,  and  has  not  had  sufficient  energy  positively  to 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.        347 

refuse  to  give  her  the  unnecessary  treatment  that  she  wanted.  We  can- 
not begin  to  number  the  women  whom  we  have  seen,  as  often  at  the 
hospital  as  in  town,  who  have  been  victims  of  such  local  gynaecological 
treatment.  The  thing  of  which  the  patients  must  be  convinced  is,  that, 
if  they  go  on  noticing  and  worrying  themselves  in  this  unnecessary 
way  about  their  genital  organs,  they  will  develop  into  confirmed  neuro- 
paths, whose  life  will  be  as  insupportable  to  themselves  as  to  their 
families, 

IV.  FuNCT^iONAL  Manifestations  in  the  Respiratory  Apparatus; 

Among  the  very  numerous  functional  manifestations  which  may 
be  localized  in  the  respiratory  apparatus,  there  are  some  which  are  purely 
phobic,  and  which  do  not  seem  to  us  to  require  any  very  lengthy  de- 
scription, as  their  treatment  in  no  way  differs  from  that  of  all  the 
other  fixations,  which,  being  of  a  purely  subjective  nature  and  without 
any  peripheral  causes,  require  nothing  more  than  a  few  psychothera- 
peutic conversations  to  cause  them  to  disappear. 

Other  troubles,  entering  into  the  domain  of  hysterical  phenomena 
or  being  caused  by  pains,  will  be  studied  with  one  or  the  other  of  these 
pathological  groupings. 

Only  a  certain  number  of  particular  indications  present  manifesta- 
tions which,  following  or  not  some  localizations  of  a  primitive  phobic 
nature,  bring  on  a  whole  series  of  objective  disturbances  which  may  some- 
times be  rather  resistant  to  therapy. 

Of  all  these  troubles  the  most  important  unquestionably  is  the  de- 
cided diminution  of  pulmonary  ventilation  which  one  finds  in  such 
a  large  number  of  neuropaths.  We  have  seen  that  the  causes  for  these 
are  generally  of  an  emotional  nature.  We  have  also  had  occasion  to 
note  the  numerous  after-effects,  sensations  of  oppression,  rapid  breath- 
ing playing  a  part  in  the  production  of  certain  asthenias,  etc. 

This  phenomenon,  which  often  passes  quite  unperceived,  should 
not  be  neglected.  There  is  a  considerable  number  of  subjects  in  whom 
a  whole  series  of  secondary  disturbances  have  resulted  more  or  less 
directly  from  bad  respiratory  habits  which  have  generally  been  created 
by  a  subcontinuous  repressed  emotion.  Psychotherapy  is  evidently  not 
enough.  If  one  has  really  found  the  presence  of  some  such  manifesta- 
tion, it  is  not  sufficient  merely  to  state  its  existence  to  the  patient  and 
to  explain  its  origin  and  consequences  to  him.  It  is  not  enough  to  tell 
a  neuropath,  ''If  you  breathe  too  rapidly  and  seem  to  have  a  feeling 
of  exhaustion,  it  is  because  you  do  not  breathe  properly;"  you  have  to 
go  still  further,  and  teach  him  how  to  breathe  in  a  normal  manner; 
you  have  to  undertake  with  him  the  work  of  respiratory  re-education. 
This  the  patient  ought  to  be  taught  to  do  while  resting  as  well  as  while 
walking.  We  shall  not  dwell  upon  the  technic  of  respiratory  educa- 
tion.    It  is  not  a  question  here  of  acquiring  a  greater  pulmonary 


348      THE  TREATMENT  OF  PSYCHONEUROSES. 

capacity,  which  is  normal  but  used  in  the  wrong  way;  no  exercises  to 
develop  strength  are  indicated.  It  will  be  enough  to  explain  to  the 
patient  in  what  way  and  just  where  he  makes  a  mistake  by  cutting 
short  the  inspiration  and  having  too  long  respiratory  pauses,  etc.,  and  in 
showing  him  just  how  a  normal  respiration  ought  to  be  taken,  and  in 
requiring  him  to  practise  it  a  certain  number  of  times  every  day.  If 
there  are  asthenic  phenomena  of  a  respiratory  origin,  when  the  patient 
begins  to  move  about,  it  will  be  necessary  for  him  always  to  pay  atten- 
tion and  to  watch  his  respirations.  If  it  is  conversation  which  causes 
him  to  be  short  of  breath  so  soon,  and  which  has  so  depressed  and 
worried  the  patient,  it  will  be  proper  for  him  to  practise  breathing  in 
a  normal  way.  This  exercise  of  re-education  may  be  carried  on  by 
making  him  read  aloud. 

If  this  therapy  is  methodically  pursued,  and  if  neither  the  physician 
nor  the  patient  permits  himself  to  repeat  the  same  things,  one  will 
obtain  such  excellent  results  as  even  sometimes  the  unexpected  disap- 
pearance of  a  whole  series  of  phenomena,  whose  relation  to  the  respira- 
tory disturbance  had  in  the  first  place  been  passed  by  unperceived. 

The  same  kind  of  therapy  will  apply  to  individuals  who,  as  a  result 
of  any  real  pain  or  thoracic  algia,  have  immobilized  a  part  of  their 
chest.  In  such  cases  the  patient  ought  to  undress  in  order  to  go  through 
his  respiratory  exercises,  and  stand  in  front  of  a  mirror,  and  try  to 
mobilize  the  region  which  is  not  sufficiently  displaced  in  the  respiratory 
movements.  One  can,  if  need  be,  at  the  start,  mobilize  this  region  by 
any  movements  requiring  force,  such  as  flexion  or  extension,  moving  the 
shoulders  or  the  arms  according  to  the  type  of  the  immobilization  which 
one  has  to  deal  with. 

This  method  of  re-education  will  generally  be  very  easy  and  often 
crowned  with  complete  success  in  a  very  short  time.  It  is  also  by 
therapeutic  re-education  that  one  gets  control  of  troubles  which,  like 
nervous  pseudo-asthma,  consist  really  of  nothing  more  than  an  emotional 
attack  with  peculiar  respiratory  fixation.  The  polypnœa  of  these  sub- 
jects is,  in  fact,  more  apt  to  follow  a  period  of  apnoea  of  emotional 
origin.  The  simple  advice  to  breathe  deeply  and  profoundly,  as  soon 
as  one  is  seized  with  that  kind  of  respiratory  anguish  which  is  the 
forerunner  of  his  symptoms,  is  sometimes  sufficient  to  enable  the  patient 
to  get  entire  control  of  his  trouble,  if,  above  all,  which  goes  without 
saying,  he  has  clearly  understood  the  mechanism.  But  in  such  subjects 
one  must  not  forget  that  outside  of  acute  attacks  there  ordinarily  exists 
a  state  of  subcontinued  oppression  which  respiratory  education  could 
quickly  terminate. 

Re-education  will  be  found  to  dispel  coughs  following  pulmonary 
phobia  or  laryngeal  fixations,  and  is  a  mode  of  treatment  to  be  used 
for  aphonia  and  ''lost  voice.''  But  here  the  indications  become  much 
more  complex.  One  must  try  to  force  the  patient  to  turn  his  attention 
from  his  functional  fixation.     The  object  of  general  psychotherapy, 


THERAPY  OF  FUNCTIONAL  IVIANIFE STATIONS.        349 

while  reassuring  the  subject  and  explaining  to  him  what  is  the  matter 
with  him,  is  evidently  to  render  him  less  attentive  to  his  fixations.  On 
the  other  hand,  once  a  patient's  attention  has  been  drawn  to  some 
symptom  for  one  reason  or  another,  or  fixed  on  some  phenomenon 
acquired  by  habit  that  has  a  tendency  to  reproduce  itself,  it  is  necessary 
that  he  should  know  how  in  some  way  to  control  his  symptoms.  He 
must  try  to  prevent  himself  from  coughing  even  when  he  feels  the 
desire  to  cough.  Even  if  his  voice  has  a  tendency  to  die  away,  he  must 
force  himself  to  speak  loudly  and  intelligibly.  jOne  will  not  always 
obtain  this  result  at  the  first  attempt,  and  the  will  of  the  patient,  which 
supports  the  conviction  of  the  neuropathic  nature  of  the  symptoms  which 
he  presents,  would  not  be  strong  enough  to  give  him  the  mastery. 
A  whole  series  of  processes  could  be  brought  in  to  help  the  patient,  or 
to  assure  his  progressive  re-education.  Drawing  long  breaths,  making 
him  swallow  saliva,  taking  a  book  and  reading  aloud,  will  often  be 
sufficient  to  inhibit  the  reflex  habit  which  constitutes  the  nervous  cough. 

As  for  the  patients  afflicted  with  aphonia,  one  could  require  them 
to  exercise  their  voices  in  the  silence  of  their  own  rooms,  or  out  in  the 
open  country-,  by  pronouncing  aloud  the  different  vowels  which  bring 
the  vocal  cords  into  action.  For  these  latter  patients,  if  their  fixation 
dates  back  for  a  long  time,  it  might  be  useful  to  insist  for  a  few  days 
upon  absolute  vocal  rest.  During  this  period  of  rest  a  great  many  of 
their  apprehensions  disappear,  and  re-education  becomes  extremely  easy. 

We  noted,  in  the  course  of  our  study  of  respiratory  fixations,  the 
comparative  frequency  of  a  symptom  which  has  nothing  to  do  with 
the  respiratory  apparatus,  except  that  it  originated  there.  We  refer  to 
the  phobia  of  cold.  Those  patients  who  are  afraid  of  catching  cold, 
or  of  starting  up  some  old  pulmonary  lesion  which  has  long  since  been 
healed,  often  get  to  the  point  where  they  can  no  longer  bear  the 
slightest  change  of  temperature  without  being  extremely  upset.  It 
sometimes  happens  that,  by  the  simple  action  of  psychotherapy  and 
authority,  the  physician  gets  his  patient  to  the  point  where  he  has  given 
up  all  his  bad  habits.  But,  in  spite  of  the  most  persuasive  argiunents, 
it  will  also  happen  that,  even  though  the  patient  is  convinced  in  his 
mind,  he,  nevertheless,  cannot  control  his  fears.  This  is  where  re-edu- 
cation has  more  chance  of  lasting  success.  It  might  consist  in  asking 
the  patient  to  gradually  overcome  his  phobic  preoccupations  by  making 
successive  trials,  or  it  might  also  be  carried  on  in  a  less  direct  manner. 
We  have  been  able  to  cure  a  patient  of  the  phobia  of  cold  by  prescribing 
him  douches  with  two  jets,  of  which  the  temperature  is  every  day  a 
little  high  in  one  and  lower  in  the  other.  The  day  when  the  patient 
could  stand,  without  any  emotional  reaction,  being  sprayed  first  with 
a  jet  that  was  very  warm  and  afterward  by  a  jet  of  very  cold  water  we 
considered  him  cured. 

The  study  of  special  therapeutic  indications  of  respiratory  fixation 
is  particularly  interesting  in  this  respect,  that  in  it  one  finds  the  dif- 


350      THE  TREATMENT  OF  PSYCHONEUROSES. 

ferent  mechanisms  on  which  re-education  may  act  distinctly  isolated. 
First  of  all,  there  is  the  whole  category  of  disharmonie  phenomena 
which  have  been  established  unknown  to  the  patient,  and  which  are  the 
old  or  recent  results  of  disturbances  which  the  psychism  of  emotion 
has  created.    For  these  symptoms  re-education  is  the  only  therapy  which 
will  allow  us  to  feel  sure  of  their  disappearance.    There  is  also  a  whole 
series  of  disturbances  which  are  directly  engendered  by  emotion  or 
attention.     It  is  certain  that  pure  psychotherapy  can  make  them  dis- 
appear.    It  is  evident  that  a  patient  who  is  sufficiently  energetic  and 
properly  informed  may  get  to  the  point,  by  means  of  his  own  will, 
where  he  first  neglects  his  discomforts  and  ends  by  forgetting  them. 
But  where  this  therapy  is  used  by  any  physicians  except  those  of  a 
good  deal  of  authority,  it  may  often  fail.    But,  if  care  be  taken  in  the 
method,  the  processes  which  are  called  re-educative  will  prove  a  con- 
venient means  of  turning  the  attention  of  the  patient  and  of  interrupting 
the   diffusion   of  emotional   phenomena.      They  have   furthermore   the 
advantage  of  suppressing  all  apprehension  on  the  part  of  the  subject, 
and  if  the  latter,  in  spite  of  the  general  psychotherapeutic  action,  does 
not  immediately  feel  security,  re-education  nevertheless  enables  him  to 
get  to  the  point  of  establishing  this  feeling  of  security,  which,  although 
it  may  come  gradually,  is  none  the  less  solidly  established.     Thus,  if 
after  explaining  things  to  him,  we  tell  a  patient  to  make  light  of  his 
cough  or  his  aphonia  or  his  pleural  asthma,  we  may  perhaps  succeed 
in   causing  the  immediate   disappearance   of  these   phenomena,   which 
under  sufficient  psychotherapeutic  influence  will  have  lost  the  psychic 
substratum  or  the  emotion  necessary  to  their  apparition.     But  it  may 
also  happen  that  the  subject  with  a  feeling  of  apprehension  will  say 
to  himself,  ''I  shall  never  be  able  to  control  my  aphonia,  or  my  cough, 
or  my  sense  of  oppression,"  and  that  he  will  get  into  a  more  emotional 
condition  concerning  it.     The  methods  of  re-education  by  asking  the 
patient  for  a  more  frequently  repeated  but  less  intense  voluntary  action 
will  not  have  this  inconvenience.     On  the  other  hand,  as  we  shall  see 
further  on,  the  choice  between  the  therapy  of  gentleness  which  is  seen 
in  methods  of  re-education  and  the  therapy  of  authority,  bringing  the 
patientas  whole  will  suddenly  into  play,  ought  to  be  made  according  to 
the  various  situations  in  which  the  patient  and  the  physician  find  them- 
selves.   It  cannot  help  but  be  interesting  to  point  out  that  re-education 
is  a  necessary  element  when  it  comes  to  substituting  for  a  bad  habit 
a  new  habit  which  is  only  a  return  to  the  normal,  and  that  in  such 
patients,  in  fact,  much  depends  on  it. 

V.  Special  Therapy  in  Cardiovascular  Manifestations. 

Cardiac  fixations  of  the  psychoneuroses  will  not  delay  us  long.  If 
practically  the  number  of  heart  phobias  and  false  cardiopaths  is  con- 
siderable, these  patients  do  not  offer  any  especial  therapeutic  indications. 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.        351 

Although,  on  the  other  hand,  a  whole  series  of  troubles,  which  w^e 
have  described  at  some  length,  may  result  from  the  action  of  emotion 
on  the  heart,  yet  in  such  cases  there  is  evidently  no  possibility  of  re- 
education working  any  direct  effect  upon  this  functional  trouble.  That 
which  must  be  combated  is  the  emotionalism  itself,  and  the  psychic 
convictions  which  encourage  it,  and  perhaps  help  to  narrow  the  emotional 
actions  into  some  special  physical  channel.  Only  psychotherapy  can 
play  a  true  therapeutic  rôle.  To  explain,  and  reassure  and  re-establish 
the  patient's  confidence,  to  turn  his  attention  to  other  things  while  re- 
directing the  course  of  his  existence,  to  absolutely  forbid  him  to  watch 
himself  or  to  feel  his  pulse  or  listen  to  his  heart-beats, — such  would 
be  the  course  of  action  among  other  things  which  the  physician  will 
have  to  put  into  practice  and  which  are  really  after  all  very  simple. 
In  the  great  majority  of  cases  a  favorable  result  is  obtained,  once  the 
patient's  idea  is  * 'switched  off."  As  for  the  patients  who  are  afflicted 
with  vascular  disturbances,  who  are  phobic  concerning  pain  in  their 
breast,  or  arteriosclerosis,  or  whose  emotionalism  has  vasomotor  expres- 
sions, they  do  not  indicate  the  necessity  for  any  particular  treatment, 
and  should  be  managed  in  the  same  way  as  the  false  cardiopaths. 

VI.  Functional  Manifestations  op  the  Skin. 

Functional  manifestations  of  the  skin  do  not  require  any  very  long 
therapeutic  commentary.  Skin  phobias  are  curable  by  ordinary  methods, 
and  the  only  fixation  on  which  we  need  to  dwell  is  that  which  is  offered 
by  those  suffering  from  neuropathic  pruritus.  These  are  sometimes  ex- 
tremely difficult  to  cure.  Patients  are  obsessed  upon  the  subject  to  a 
degree  that  one  can  hardly  imagine,  and  it  is  often  absolutely  necessary 
to  treat  them  in  isolation.  General  psychotherapeutic  treatment  will 
sometimes  produce  immediate  results,  but  this  is  rather  unusual,  and  it 
is  very  apt  to  be  the  case  that  the  cure  of  such  subjects  will  require  a 
considerable  length  of  time. 

The  therapeutic  regulations  which  should  be  laid  down  are  as  fol- 
lows: First  of  all,  as  far  as  possible,  an  attempt  must  be  made  to  get 
the  patient's  attention  from  his  fixation.  This,  as  a  rule,  is  not  an 
easy  thing.  However,  by  engaging  in  rather  long  conversations  with 
him,  or  in  getting  somebody  else  to  undertake  this,  one  will  succeed  in 
making  him  forget  his  trouble  momentarily.  The  fact  that  under  the 
influence  of  a  different  set  of  ideas  the  patient  can  pass  a  greater  or  less 
length  of  time  without  feeling  his  itching  will  furnish  an  excellent 
psychotherapeutic  argument  for  him  to  bring  his  will  into  direct  play. 
According  to  circumstances,  other  methods  of  distraction  than  conversa- 
tion could  be  employed,  such  as  reading,  or  manual  or  intellectual  work  ; 
the  ingenuity  of  the  physician  will  have  to  be  called  forth  to  find  the 
best  methods  to  use  in  order  to  turn  the  patient's  attention  away  from 
his  itching. 


352     THE  TREATMENT  OF  PSYCHONEUROSES. 

The  patient  must  attempt  to  resist  the  temptation  to  scratch,  even 
if  he  feels  the  greatest  need  for  doing  so.  As  it  often  happens  that 
patients  who  are  very  badly  affected  seem  almost  unconsciously  im- 
pelled to  scratch  themselves,  it  is  necessary  to  put  some  obstacle  in 
the  way  to  prevent  them  from  scratching,  so  that,  before  they  yield  to 
the  impulsion,  the  material  obstacle  forces  them  to  take  time  to  think 
about  it.  Thus,  for  example,  in  putting  the  patient  into  a  bed  in  which 
the  covers  are  very  carefully  tucked  in  or  fastened  down,  during  the  time 
that  it  will  require  for  him  to  free  himself  from  his  covering  he  will 
have  had  the  opportunity  of  getting  hold  of  himself  and  will  be  able  to 
control  his  desires. 

A  sort  of  re-education  may  also  be  carried  on  at  the  same  time  by 
asking  the  patient  to  allow  a  longer  and  longer  time  between  the  periods 
when  he  must  relieve  himself  by  scratching.  This  method  seems  to  us 
dangerous,  because  during  the  whole  interval  in  which  the  patient  is 
forbidden  to  scratch  himself  he  will  probably  think  of  nothing  else 
than  of  the  moment  when  it  will  be  allowed  him,  and,  however  strong 
may  be  his  self-mastery  and  the  power  of  his  will,  the  obsession  will 
have  every  chance  to  increase. 

In  fact,  to  prove  to  the  patient  experimentally,  and  by  distraction, 
that  he  can  allow  a  considerable  time  to  pass  without  feeling  the  need 
of  scratching,  and  to  interpose,  on  the  other  hand,  mechanical  obstacles 
between  the  idea  of  scratching  and  its  realization, — such  are  the  two 
essential  elements  of  treatment.  General  psychotherapy  naturally  is  as 
beneficial  here  as  elsewhere. 

What  we  have  already  said  concerning  patients  afflicted  with  phobias 
of  cold  spares  us  the  necessity  of  giving  the  particular  treatment  of 
these  patients  who  have  educated  themselves  in  thermic  sensibility,  whom 
we  meet  so  frequently,  and  whose  troubles  are  either  primitive,  or 
secondary  to  a  phobic  condition  connected  with  the  respiratory 
apparatus. 


CHAPTER  XXV. 

SPECIAL    THERAPY    OF    FUNCTIONAL    MANIFESTATIONS    (CONTINUED). 

All  the  functional  manifestations  which  now  remain  for  us  to  study 
from  a  therapeutic  point  of  view  belong  in  different  degrees  to  the 
domain  of  the  central  nervous  system  or  its  peripheral  projections.  These 
manifestations  are  innumerable,  but  those  which  are  of  an  hysterical 
nature  will  be  taken  up  therapeutically  further  on.  Some  manifesta- 
tions are  purely  phobic  in  their  nature,  and  do  not  present  any  special 
indications.  There  are,  however,  many  others  among  these  disturbances 
which  show  very  special  and  definite  therapeutic  indications,  which  it 
seems  to  us  wise  to  develop  somewhat. 

Abandoning  for  a  moment  the  functional  classifications  which  we 
have  adopted  in  the  first  part  of  our  work,  there  is,  first  of  all,  a  group 
of  symptoms  which  we  want  to  study,  and  which  may  be  brought  to- 
gether under  the  name  of  symptoms  of  fatigue.  Neurasthenics,  in 
regard  to  the  fatigue  which  they  nearly  always  experience,  may  be 
divided  into  three  classes.  There  are  some  subjects  who  are  simply 
phobic,  and  who  have  never  had  any  possible  reason  whatsoever  to  ex- 
perience or  more  particularly  to  dread  fatigue.  There  are,  on  the  other 
hand,  patients  who,  having  originally  suffered  from  true  fatigue,  have 
afterward  remained  subjectively  exhausted,  but  in  a  way  which  is  purely 
psychic.  There  are,  finally, — and  this  is  the  class  of  patients  which, 
for  the  time  being,  we  are  considering  alone, — those  who  are  really 
fatigued.  That  emotion  may  give  rise  to  a  real  fatigue  which  at  the 
same  time  is  psychic  and  physical  is  very  well  known,  and  there  is  no 
doubt  that  the  repeated  and  continuous  action  of  any  emotional  pre- 
occupation leads  likewise  to  this  result.  If,  on  the  other  hand,  the  fact 
be  taken  into  consideration  that  a  great  many  neurasthenics  are  very 
much  emaciated  and  for  weeks,  months,  and  sometimes  years  have  been 
inadequately  nourished,  it  can  be  seen  that  there  are  patients  to  whom  it 
would  be  preposterous  to  attribute  the  feelings  of  fatigue  of  which  they 
complain  to  a  purely  psychic  origin.  A  therapeutic  mistake  which  is  often 
made  consists  in  prescribing,  for  such  weakened  people,  more  or  less 
violent  exercises,  which  are  supposed  to  be  useful  in  breaking  up  their 
emotional  condition  and  calming  their  irritability,  or  simply  for  the 
purpose  of  getting  them  in  training.  By  this  method,  however,  nothing 
but  physical,  moral,  and  intellectual  depression  of  a  more  pronounced 
type  will  result. 

Although  all  neurasthenias  are  emotional  in  origin,  as  we  think  that 
we  have  fully  proved,  yet  all  emotional  conditions  do  not  always  neces- 
sarily result  in  psychic  phenomena,  or  phenomena  of  suggestion  or 
23  353 


354      THE  TREATMENT  OF  PSYCHONEUROSES. 

inhibition  due  to  pathological  convictions.  It  seems  to  us,  then,  that^ 
in  the  case  of  patients  who  are  both  physically  and  psychically  de- 
pressed on  account  of  continued  emotional  causes,  the  therapeutic  in- 
dications point  very  definitely  to  rest  and  overfeeding,  and  if  necessary, 
in  cases  of  very  marked  depression  or  excessive  irritability,  to  isolation, 
which  is  here  a  very  essential  condition  of  proper  rest. 

It  is  very  easy  to  lay  down  such  rules  for  patients  who  appear  ob- 
jectively to  be  very  much  exhausted.  But  what  is  much  more  difficult 
is  to  determine  the  precise  moment  where  it  seems  to  be  right  to 
terminate  this  preliminary  but  necessary  period  of  treatment  and  to 
get  the  patient  by  easy  progressive  stages  into  the  line  of  treatment 
which  we  shall  indicate.  It  will  often  happen,  that,  if  the  work  of 
psychotherapy  has  been  normally  carried  on  during  this  first  phase  of 
treatment,  and  if  the  patient  has  been  relieved  of  all  the  moral  and 
psychic  complications  of  his  condition,  he  will  be  able  himself  to  give 
you  very  valuable  information,  and  that  it  will  happen  quite  naturally, 
when  the  rest  has  been  sufficient  to  cause  his  fatigue  to  disappear,  that 
he  will  again  feel  the  need  of  entering  into  active  life,  taking  up  his 
affairs  and  putting  forth  new  energy. 

It  will  be  wise  for  the  physician  to  grant  him  any  such  legitimate 
desires,  bearing  in  mind,  however,  all  the  time,  this  fact,  that  he  has  to 
deal  with  a  patient  who,  by  reason  of  having  rested,  is  wholly  out  of 
training,  and  who  finds  himself  in  almost  exactly  the  same  situation  as  a 
convalescent  who  is  going  out  for  the  first  time.  The  part  which  the 
physician  must  then  play  is  that  of  moderation  ;  he  must  hold  his  patient 
back,  and  not  permit  him  to  make  any  efforts  except  those  which  are 
regularly  progressive.  Moreover,  such  patients,  once  started  off  and 
put  upon  the  right  road  by  general  psychotherapy,  very  rarely  present 
any  serious  therapeutic  difficulties,  provided,  however,  that  they  have 
not  been  allowed  to  retain  any  of  their  former  dread  of  fatigue. 

As  a  matter  of  fact,  it  will  happen  also,  although  not  very  often,  that 
even  after  a  sufficiently  prolonged  rest  the  patient  will  still  consider 
himself  as  suffering  from  fatigue,  and  that  all  effort  on  his  part  will  be 
accompanied  by  a  greater  or  less  feeling  of  apprehension.  Where  he 
was  once  merely  fatigued  he  has  now  become  phobic,  or  rather,  though 
the  real  elements  of  fatigue  have  disappeared,  the  subjective  elements 
have  persisted. 

Is  there  any  objective  idea  whatsoever  which  will  enable  the  phy- 
sician to  tell  exactly  when  the  time  has  come  for  him  to  make  his  pa- 
tients take  up  their  responsibilities,  whatever  may  be  their  fears  or 
their  persistent  convictions  concerning  them  ?  For  instance,  what  should 
we  do  when  we  have  a  patient  who  is  afraid  to  put  his  foot  on  tho 
ground  but  who  is  very  restless  in  bed?  Under  such  circumstances  the 
thing  which  would  give  us  the  most  positive  light  on  the  subject  is 
the  patient's  increase  in  weight.  Any  patient  who,  having  lost  a  greater 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.         355 

or  less  number  of  pounds,  has  almost  regained  his  normal  weight  may 
be  restored  progressively  to  physical  activity  without  inconvenience. 
We  would  not  be  far  wrong  in  thinking  that  this  should  also  be  the 
guide  to  tell  us  the  time  when  he  might  return  to  intellectual  activity. 
But  here  we  must  take  into  account  the  clinical  condition  of  patients 
at  the  time  when  their  treatment  commenced.  This  is  because,  as  a 
matter  of  fact,  psychic  depressions  and  physical  depressions,  however 
closely  associated  they  may  be,  do  not  necessarily  follow  a  strictly  parallel 
course.  There  are  many  subjects  whom  emotional, fatigue  has  affected 
more  in  the  domain  of  their  psychic  faculties  and  less  in  their  physical 
activities.  There  is  a  small  number  of  patients,  on  the  other  hand, 
who,  although  very  emaciated,  have  nevertheless  preserved  the  ability 
to  accomplish  a  certain  amount  of  intellectual  work.  The  disappearance 
of  the  phenomena  of  irritation  at  noise  will  be  of  importance  ;  but  what 
perhaps  can  better  guide  the  practitioner,  and  enable  him  to  divert  all 
the  subjective  elements  of  the  persistence  of  an  intellectual  fatigue,  is 
the  manner  in  which  the  patient  behaves  during  the  course  of  psycho- 
therapeutic conversations.  The  subject  whose  brain  is  truly  fatigued 
reasons  very  little  if  at  all.  From  the  moment  he  begins  to  discuss  and 
reply,  and  from  the  moment  that  you  see  that  in  the  interval  between 
the  psychotherapeutic  conversations  he  has  been  reflecting  upon  things 
of  his  own  accord,  you  may  without  fear  let  him  go  back  to  some 
intellectual  work,  of  which,  however,  you  must  measure  the  quantity 
to  be  permitted  at  a  time. 

In  other  words,  a  return  to  normal  ways  and  a  spontaneous  return 
of  intellectual  activity  which  is  in  some  degree  unpremeditated  :  these  are 
the  elements  which  permit  one  to  consider  that  the  preliminary  treat- 
ment of  the  various  aids  to  psychotherapy  has  been  sufficient. 

The  time  which,  as  a  matter  of  fact,  will  be  devoted  to  such  treat- 
ment must  evidently  vary  according  to  the  degree  in  which  particular 
cases  are  affected.  In  the  majority  of  cases  from  six  weeks  to  two 
months  are  sufficient,  and  the  cases  are  less  frequent  where  this  part  of 
the  treatment  must  be  prolonged  for  several  months.  It  will  more 
often  be  found  that  this  time  has  by  no  means  been  lost,  because  it  will 
have  given  a  very  excellent  opportunity  for  psychotherapeutic  treat- 
ment. 

Let  us  hasten  to  add  that  cases  of  neurasthenia,  with  or  without 
functional  manifestations,  which  require  a  very  prolonged  rest,  are  rare, 
and  that  the  important  thing  is  not  to  confuse  real  fatigue  with  sub- 
jective fatigue. 

Now  that  we  have  explained  ourselves  concerning  those  facts  which 
we  are  inclined  to  consider  as  exceptional,  we  can  continue  the  thera- 
peutic study  of  the  functional  manifestations  to  which  there  is  no 
physical  substratum,  which  has  not  been  the  case  in  those  thus 
referred  to. 


356      THE  TREATMENT  OF  PSYCHONEUROSES. 

I.  The  Therapy  of  Functional  Disturbances  in  the  Neuro-muscular 

Apparatus. 

For  the  moment  we  shall  leave  untouched  all  hysterical  manifesta- 
tions, contractures,  paralyses,  choreas,  and  tremblings,  and  shall  take 
up  only  physical  asthenia  on  the  one  hand  and  disturbances  of 
equilibrium  on  the  other. 

A.  Physical  Asthenia. — Setting  aside  all  the  exceptions  which  we 
made  in  the  cases  which  we  considered  in  the  preceding  paragraphs,  we 
shall  now  consider  only  those  subjects  whose  fatigue  is  purely  objective, 
or  who,  having  originally  been  greatly  fatigued,  have  remained  so  and 
do  not  seem  to  be  able  by  means  of  rest  to  get  back  their  old  strength, 
and  who,  as  a  matter  of  fact,  are  really  suffering  from  secondary 
phobias. 

The  asthenia  of  these  patients  is  made  up  under  such  circumstances 
of  two  different  phenomena,  psychic  phenomena  on  the  one  hand,  con- 
sisting of  conviction  of  helplessness  and  of  apprehension  concerning  all 
kinds  of  tire,  and  disharmonie  phenomena  on  the  other  hand,  which 
are  the  more  or  less  direct  results  of  that  very  apprehensiveness  from 
which  the  patient  suffers.  We  dwelt  for  a  long  time  upon  these  points 
in  the  first  part  of  our  work,  so  that  it  is  not  necessary  to  go  over  them 
again. 

What  therapy  shall  one  bring  to  bear  upon  these  manifestations? 
Psychotherapy  will  undoubtedly  do  the  work,  but  it  must  be  experi- 
mentally demonstrated  to  the  patient  that  he  is  capable  of  making 
physical  efforts.  It  is  very  evident  that  one  must  work  his  training. 
But  here  one  encounters  a  series  of  small  practical  difficulties  which  one 
must  know  how  to  handle.  It  is  by  no  means  enough  to  say  to  a  patient, 
*' To-day  you  must  walk  for  two,  three,  four,  or  five  minutes;  and 
every  day  hereafter  you  must  increase  by  a  given  time  your  walking 
and  any  other  exercise  which  may  have  been  prescribed.  '  '  If  his  train- 
ing is  outlined  in  such  a  manner,  there  will  be  great  likelihood  that  it 
will  amount  to  nothing,  or  have  but  indifferent  results,  and  will  only 
succeed  in  strengthening  in  the  patient  the  psychic  conviction  of  his 
physical  helplessness. 

Anything  which  is  apt,  in  any  kind  of  training,  to  fix  the  patient's 
attention  on  the  probable  appearance  of  fatigue  is  dangerous;  because, 
as  a  matter  of  fact,  the  moment  the  attention  is  fixed  upon  the  idea, 
subjective  fatigue  will  immediately  appear,  and  from  that  will  come 
disharmonie  phenomena  which  will  make  the  fatigue  effective. 

Hence,  from  the  moment  the  training  is  begun,  a  certain  number 
of  precautions  should  be  laid  down.  Later,  when  the  patient  has  made 
a  certain  amount  of  progress,  he  will  be  convinced  that  he  can  get  back 
his  old  physical  activity  in  this  way,  and  then  they  will  be  unnecessary, 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.        357 

for  the  subject,  being  reassured  and  more  confident,  will  carry  on  his 
training  alone. 

These  precautions  are  of  various  kinds.  First  of  all,  it  is  evident 
that  one  must  avoid  the  occurrence  of  any  disharmonie  phenomena  which 
might  become  habits,  such  as  rapid  breathing  due  to  insufficient 
respiration,  or  walking  stiffly,  which  will  bring  on  rapid  fatigue.  The 
patient,  therefore,  must  be  told  to  walk  in  such  a  way  that  he  can 
accomplish  it  slowly  and  easily,  to  try  **to  keep  step,"  as  we  are  accus- 
tomed to  tell  him,  and  to  stop  frequently  and  breathe  deeply.  It  is  not 
always  wise — but  that  depends  upon  particular  cases — to  give  the  patient 
a  set  time  during  which  he  should  walk,  and  then  a  fixed  time  during 
which  he  should  rest.  It  will  often  happen,  if  this  is  the  case,  that  the 
patient  with  his  watch  in  his  hand  will  fix  his  attention  upon  his  walk- 
ing, and  will  feel  subjective  fatigue  coming  on  quickly.  The  best  way 
certainly  would  be  for  this  kind  of  trainiag  to  be  undertaken  with  a 
physician.  It  would  then  be  he  who  would  take  all  the  responsibility, 
and  who  would  determine  according  to  the  patient's  mental  condition 
the  times  to  rest  and  the  time  to  walk,  while  at  the  same  time  by  means 
of  conversation  he  would  keep  the  patient  from  all  auto-observations; 
but  it  is  evident  that  this  is  far  from  being  always  possible.  Things 
must  be  managed  differently,  and  the  surest  method  seems  to  us  to 
be  the  following.  It  consists  not  in  giving  the  patient  a  minimum,  but 
a  maximum  time  to  walk.  ** To-day,"  you  wiU  t^U  him,  **you  will 
walk  not  more  than  half  an  hour  during  the  day."  In  this  way,  the 
patient  is  not  haunted  with  anxiety  if  he  does  not  fulfil  the  conditions 
of  his  task.  On  the  other  hand,  the  time  he  is  to  watch  is  not  that 
devoted  to  walking,  but  that  which  is  to  be  given  to  rest.  He  leaves  at 
a  given  time,  armed  with  his  camp-chair,  if  he  is  ia  a  place  where 
there  are  not  apt  to  be  any  seats.  He  walks  for  a  certaia  length  of  time 
along  the  road, — ^no  matter  where,  provided  that  it  is  a  distance  that  he 
thinks  he  can  accomplish  without  fatigue  and  which  will  not  cause  him 
any  apprehension.  He  sits  down,  looks  at  his  watch,  and  rests  as  long 
as  it  seems  to  him  necessary.  The  moment  he  starts  again,  he  looks  at 
the  time  and  calculates  how  long  he  has  rested  ;  and  by  this  method,  by 
the  simple  act  of  subtraction,  he  will  at  the  end  know  the  exact  time 
that  he  has  been  walking.  At  no  time  in  this  way  is  his  attention  fixed 
upon  his  walking,  not  even  during  the  time  when  he  is  actually  doing  it. 

One  will  be  astonished,  if  one  proceeds  in  this  way,  at  the  rapidity 
with  which  the  patient  in  most  cases  will  completely  lose  his  sense  of 
fear,  and  will  reach  the  point  where,  subjectively  as  well  as  practically, 
he  wiU  behave  like  a  normal  individual. 

It  is  very  evident  that  walking  is  not  the  only  kind  of  training  and 
development  which  the  physician  wiU  be  called  upon  to  regulate.  All 
forms  of  physical  activity  may  be  affected,  either  simultaneously  or — 
what  is  much  more  curious — one  at  a  time.      Patients  are  seen  who  say 


358      THE  TREATMENT  OF  PSYCHONEUROSES. 

that  they  are  quite  able  to  walk  for  an  hour,  but  unable  to  stand  still 
for  five  minutes. 

Now,  the  training  which  is  necessary  to  enable  one  to  stand  is  one 
of  those  which  offers  the  greatest  difficulties.  Here,  again,  disharmonie 
phenomena  come  in.  One  must  be  very  particular  to  make  the  patient 
understand  that  standing  upright  does  not  mean  to  hold  one's  self 
absolutely  rigid  and  fix  one's  self  in  a  position  which  may  not  be 
changed  even  to  draw  a  breath.  It  will  often  be  easy  to  give  him  some 
direct  proof  that  it  is  quite  possible  for  him  to  remain  standing  much 
longer  than  he  thinks  he  can.  All  that  is  necessary  to  do  this  is  to 
change  the  trend  of  his  ideas  by  means  of  conversation,  and  to  attack 
his  pathological  convictions  as  it  were  by  surprise.  This  duty  may 
then  devolve  upon  some  friend  of  the  patient  or  some  one  who  is  in 
his  household.  It  may  happen  that  in  your  presence  the  patient  will 
be  somewhat  defiant,  and  that  he  will  try  to  give  you  some  objective 
proof  of  his  subjective  incapacity.  It  happens  in  the  same  way  in 
some  circumstances  for  walking  as  well  as  for  standing,  and  also  for 
any  other  kind  of  particular  physical  incapacity,  that  one  will  have  to 
break  through  the  pathological  convictions  in  which  the  patient  has 
bound  himself  up  by  surprising  him.  This  method  can  be  adopted  as 
well  whether  it  is  a  case  of  general  asthenia  or  one  or  other  of  the  localized 
asthenias  that  we  have  studied. 

But  in  a  general  way,  all  this  therapy  ought  to  be  summed  up  at 
the  beginning  in  these  words, — ^re-education  without  drawing  attention 
to  it. 

It  will  happen,  however,  that  in  a  great  many  cases  so  many  pre- 
cautions will  be  quite  unnecessary,  and  that,  having  fully  penetrated 
the  psychism  of  your  patient,  you  will  have  been  able  to  awaken  in  him 
a  sufficient  desire  for  new  activity  and  a  sufficiently  strong  conviction 
of  a  possibility  of  such  activity  as  to  make  his  training  take  place  as 
naturally  as  if  there  were  nothing  more  serious  the  matter  than  is  the 
case  in  the  convalescence  of  any  individual  who,  having  been  inactive 
for  a  long  time,  for  any  reason  whatsoever,  independent  of  hià  psychism 
and  his  will,  is  anxious  to  get  back  his  customary  activity. 

B.  Disturbances  of  Equilibrium. — Many  of  these  disturbances  be- 
long largely  to  hysteria,  but  they  are  far  from  being  rare  in  neuras- 
thenics, as  a  result  of  phobic  phenomena.  These  are  the  subjects  who, 
believing  or  fearing  that  they  are  afflicted  with  some  disease  of  the 
brain  or  of  the  spinal  cord,  or  experiencing  some  form  of  vertigo,  think 
that  their  kinetic  or  static  equilibrium  is  no  longer  true.  By  making  a 
series  of  false  movements  in  order  to  maintain  equilibrium,  which  is 
really  in  no  danger  of  being  disturbed,  they  get  to  the  point  by  dis- 
harmonie troubles  where  they  sometimes  make  it  still  more  uncertain. 
To  explain  this,  and  convince  them,   and  re-educate  them  are  three 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.        359 

steps  of  treatment  for  these  cases.  Their  re-education  will  consist  simply 
in  making  the  patient  walk  with  somebody  near  him — it  is  very  rarely 
necessary  to  support  him — so  that  he  has  a  sense  of  security,  then  to 
ask  him  to  go  on  to  the  point  where  he  will  simply  hold  a  stick  in  his 
hand  to  preserve  his  equilibrium  in  case  he  feels  that  he  is  going  to 
lose  it,  and  finally  in  making  him  walk  alone  without  any  aid. 

In  a  general  way,  the  therapy  of  these  disturbances  in  neurasthenics 
is  very  easy,  and  does  not  require  any  lengthy  consideration.  But  here, 
naturally,  one  must  at  the  same  time  try  to  make  over  the  patient's 
mental  state. 

II.  Special  Therapy  of  Disturbances  of  Sensibility.     Pains. 

We  will  not  dwell  upon  the  objective  disturbances  of  sensibility 
which  for  the  most  part  spring  from  hysteria.  The  only  phenomenon 
which  one  may  come  across,  also,  among  neurasthenics,  is  generalized 
hyperaesthesia  due  to  psychic  irritability.  This  trouble  stands  in  relation 
to  the  subcontinuous  emotional  state  in  which  the  patient  finds  himself. 
As  such,  it  is  susceptible  to  general  psychotherapy.  When  it  is  very 
marked,  it  may  be  necessary  to  isolate  the  patient,  who,  as  soon  as  he 
receives  only  the  minimum  of  sensations  and  excitations,  will  quite  soon 
forget  the  hyperexcitability  which  was  preoccupying  him. 

From  the  special  point  of  view  with  which  we  are  concerned,  the 
pains  are  much  more  interesting.  They  are  nervous  manifestations, 
which,  as  a  matter  of  fact,  are  extremely  difficult  to  cure  in  many  cir- 
cumstances. Certain  patients  are  so  systematized,  the  pains  which  they 
feel  create  such  violent  impressions  upon  them,  that  in  certain  cases  it 
is  almost  impossible  to  draw  their  attention  away  from  them  by  any 
method  whatsoever.  The  pain  sometimes  occurs  under  the  form  of  a 
type  of  obsessive  pain,  and  one  will  find  almost  as  great  a  difficulty  in 
getting  anything  to  quiet  it  as  one  would  experience  in  helping  a  mental 
case  to  get  rid  of  a  real  obsession.  The  patient  should  not  be  simply  pro- 
nounced as  incurable.  Although  the  pain  phenomena  which  are  asso- 
ciated with  the  functional  manifestations  of  different  organs,  and  which 
as  a  rule  are  only  of  mild  or  moderate  intensity,  are  often  very  quickly 
cured,  the  same  is  not  true  when  serious  algias  whose  starting-point  lies  in 
some  bodily  phenomena  have  to  be  dealt  with,  and  which  cannot  be  made 
to  disappear  with  any  ordinary  method  of  therapy. 

Everything  here  depends  on  bringing  the  energy  into  play  and  arous- 
ing the  patient's  will  by  bringing  to  bear  the  proper  general  psycho- 
therapy. It  is  necessary  for  the  subject  to  be  not  only  told,  but  con- 
vinced, of  the  neuropathic  nature  of  his  pain,  and  for  him  to  awake  to 
the  fact  that  he  must  control  it  himself.  Whoever  the  physician  may 
be  and  whoever  the  patient  may  be,  this  rule  is  for  all,  and  we  do  not 
know  of  any  other  therapeutic  method. 


360      THE  TREATMENT  OF  PSYCHONEUEOSES. 

Here,  for  example,  is  a  patient  who  is  suffering  from  a  painful  symp- 
tom which  appears  in  the  form  of  a  boring  sensation  localized  in  the 
pit  of  the  stomach.  This  pain  is  almost  continuous,  but  between  the 
times  when  it  is  practically  bearable  there  occur  in  each  day  several 
hours  when  it  is  very  much  worse,  and  when,  as  the  patient  will  say,  it 
becomes  practically  insupportable.  Whether  he  is  sitting  down  or 
whether  he  is  in  bed,  he  will  leap  up  and  begin  to  stride  about  his  room, 
clasping  his  abdomen  with  both  hands  and  uttering  deep  groans.  The 
perspiration  will  break  out  on  his  forehead,  and  he  will  get  into  a  state 
of  intense  emotion,  will  find  life  unbearable  and  plan  to  get  out  of  it. 
It  may  sometimes  happen  that  such  a  patient  may  be  cured  in  a  few 
days,  even  though  he  may  have  suffered  for  months  or  possibly  for 
years.    We  could  quote  a  great  many  examples  of  such  cures. 

In  the  majority  of  cases  isolation  is  distinctly  indicated.  It  is  not 
always  absolutely  necessary,  but  the  thing  which  is  indispensable  is  that 
the  patient  must  put  forth  a  tremendous  amount  of  energy.  When  the 
painful  sjrmptoms  are  starting  in,  it  is  necessary  for  him  to  force  him- 
self absolutely  to  keep  still.  He  must  take  a  book  and  compel  himself 
to  read  aloud,  or,  more  simply,  to  recall  what  has  been  told  him, — 
namely,  that  his  pain  will  surely  disappear  if  he  knows  how  to  get  the 
mastery  over  it.  He  must  then  calmly,  and  with  something  of  heroic 
tranquillity,  wait  for  it  to  pass.  Prom  this  first  effort  he  will  gain 
something,  because  from  the  very  start  the  duration  of  the  painful 
attack  will  be  considerably  lessened.  At  the  end  of  a  few  weeks,  some- 
times only  of  a  few  days,  nothing  will  remain  of  those  manifestations 
which  disturbed  the  patient's  life  for  so  many  months  or  years  but  a 
very  disagreeable  memory,  which  the  patient  who  is  now  wrapped  up  in 
his  cure  must  not  go  back  to  any  more  often  than  is  unavoidable. 

An  algia  is  the  type  of  functional  manifestation  which  can  be  cured 
only  by  stoical  contempt.  It  is  also  necessary,  however,  for  the  patient 
to  receive  from  a  vigorous  dose  of  psychotherapy  sufficient  faith  and 
strength  to  work  him  up  to  the  point  of  making  an  effort  which  re- 
quires that  all  his  will  and  all  his  energy  should  be  bent  upon  his  cure. 
To  try  to  cure  an  algia  by  slow  and  gentle  methods  is  almost  certain 
to  run  the  risk  of  a  set-back  from  which  the  patient  will  emerge  com- 
pletely hopeless.  It  is  almost  the  only  functional  manifestation  whose 
therapy  needs  be  so  sharp,  and  the  only  one  where  methods  of  re- 
education, of  distraction  by  surprise,  etc.,  are  unable  to  supplement  the 
patient's  deficient  will  or  the  insufficient  authority  of  the  physician. 
This  does  not  apply,  it  is  of  course  understood,  to  any  but  the  great 
central  algias,  which  are  more  often  found  in  neurasthenics  under  the 
title  of  monosymptomatic  functional  manifestations. 

All  pains  of  phobic  origin,  due  to  fixation  of  the  patient's  attention 
on  some  point  of  his  body,  and  by  the  sub-continuous  calling  forth  of 
a  pain  whose  cause  has  long  since  disappeared,  may  be  treated  in  the 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.        361 

same  way.  But  other  processes,  such  as  distraction,  turning  the  atten- 
tion away  from  the  trouble,  and  the  simple  psychotherapeutic  action  of 
explanation,  may  often  be  sufficient  to  cause  a  disappearance  of  phenom- 
ena which,  as  a  matter  of  fact,  occupy  only  a  small  place  in  the  symp- 
tomatic ensemble.  In  a  similar  way  precordial,  abdominal,  genital,  or 
perigenital  pains  can  be  made  to  disappear  at  the  start,  if  the  patient 
is  reassured  concerning  their  cause,  and  if  one  is  able  to  get  the  pa- 
tient's mind  off  of  the  possible  disease  with  which  he  believes  himself 
attacked,  and  to  arrive  by  re-education  at  the  point  where  any  functional 
trouble  that  has  presented  itself  may  be  made  to  disappear.  In  cases 
like  this  the  pain  is  for  the  patient,  or  becomes  for  him,  nothing  more 
than  a  psychic  justification  of  a  pathological  conviction;  the  disappear- 
ance of  the  pathological  conviction  brings  about  the  disappearance  of 
the  pain,  even  though  the  latter  has  been  the  origin  of  all  the  symptoms. 

III.  Therapy  of  the  Functional  Manifestations  of  the  Organs  of 

Sense. 

These  fixations  will  not  detain  us  long.  Sometimes  consisting  of 
pure  phobic  manifestations,  sometimes  resulting,  as  in  the  case  of 
irritability  to  noise,  from  a  condition  of  fatigue  or  an  emotional  state, 
sometimes  caused  by  disharmonie  disturbances,  such  as  a  deafness  of 
attention  in  those  patients  who  do  not  hear  because  they  do  not  even 
attempt  to  listen,  they  do  not  furnish  any  special  therapeutic  indica- 
tions. And  the  patient  whose  faith  is  established,  and  who  has  been 
made  to  understand  the  real  cause  of  the  troubles  which  he  presents, 
concerning  which  we  have  already  sufficiently  expatiated,  will  easily  rid 
himself  of  them. 

IV.  Therapy  of  Nervous  and  Psychic  Manifestations  Properly 

So  Called. 

Here,  on  the  other  hand,  there  are  numerous  special  therapeutic 
indications,  and,  even  though  we  eliminate  from  our  actual  study  all  the 
disturbances  which  have  any  connection  with  hysteria,  there  will  still 
remain  much  to  do  if  we  mention  all  the  processes  and  all  the  thera- 
peutic precautions  which  belong  to  these  very  specialized  localizations. 

A.  Disturbances  of  Sleep. — In  the  first  part  of  this  work  we  set 
forth  our  ideas  concerning  disturbances  of  sleep.  We  have  shown  that 
there  are  insomnias  due  to  education  in  subjects  who,  either  accidentally 
or  on  account  of  the  way  their  lives  are  arranged,  have  formed  a  habit 
of  doing  with  very  little  sleep;  insomnias  of  phobic  origin  in  patients 
whose  fear  of  not  sleeping  has  made  them  restless  and  chased  away 
their  sleep;  insomnias  due  to  the  obsessive  action  of  some  emotional 


362      THE  TREATMENT  OF  PSYCHONEUROSES. 

cause  which  exists  spontaneously  in  the  patient's  consciousness,  or  which 
he  voluntarily  keeps  recalling.  Finally  we  recall  that  there  is  a  whole 
series  of  sleep  disturbances  resulting  from  a  less  marked  state  of  pre- 
occupation or  which  are  due  to  pure  auto-suggestion.  These  are  not 
expressed  objectively  in  the  form  of  insomnia,  but  are  brought  home 
to  the  patient  in  the  form  of  simple  subjective  impressions. 

Of  all  these  manifestations  insomnia  due  to  education  is  undoubtedly 
the  one  which  is  most  difficult  to  treat.  Among  those  patients  who  have 
formed  a  habit  of  not  sleeping  more  than  an  hour  or  two  each  night, 
or  going  to  sleep  at  the  start  but  wakening  at  a  given  hour,  the  re- 
establishment  of  normal  sleep  is  often  extremely  difficult.  We  have 
seen  patients  who  without  any  question  have  been  suffering  from  severe 
neurasthenia,  but  in  whom,  with  a  physical  and  moral  symptomatology 
which  was  sometimes  extremely  complex,  their  insomnia  would  be  the 
only  thing  left  at  the  end  of  a  given  time  that  would  refuse  to  yield  to 
any  treatment.  We  do  not  hesitate  to  confess  that  as  far  as  this  mani- 
festation is  concerned  we  have  had  some  therapeutic  failures,  but  we 
have  also  had  a  certain  amount  of  success,  which  enables  us  to  lay  down 
certain  conditions  by  means  of  which  one  has  the  chance  to  obtain 
favorable  therapeutic  results. 

There  are,  first  of  all,  a  rather  large  number  of  people  who  have 
become  accustomed  to  their  insomnia  and  who  have  planned  their  lives 
accordingly,  knowing  that,  whatever  they  do,  their  sleep  comes 
rhythmically,  with  a  rhythm,  it  is  true,  that  is  insufficient,  but  never- 
theless is  perfectly  regular.  These  patients  busy  themselves  until  the 
time  when  their  regular  hour  of  sleep  is  at  hand.  They  read  or  do  some- 
thing with  their  hands.  If,  in  their  case,  it  is  the  waking  hour  which 
comes  too  early,  and  not  the  fact  that  the  hour  for  going  to  sleep  is 
delayed,  they  plan  to  fill  the  hours  which  must  pass  before  it  is  time  to 
get  up.  In  itself  this  method  of  living  is  legitimate,  for  one  must 
remember  that  they  are  wide  awake  and  feel  no  need  of  sleep,  and 
absolute  inactivity  seems  to  them  peculiarly  distressing  and  something 
which  they  try  to  avoid.  But  it  must  also  be  realized  that  in  this  way 
their  habit  is  encouraged  and  strengthened,  and  the  first  therapeutic 
indication  which  must  be  given  to  these  patients  is  to  tell  them  to  give 
up  doing  anything  whatsoever  during  the  hours  which  should  normally 
be  devoted  to  sleep.  Not  only  must  they  cut  off  any  occupation,  but, 
still  further,  they  must  try  not  to  think  about  anything  whatsoever. 
They  must  behave  exactly  as  if  they  were  going  to  sleep  again  naturally, 
but,  above  all,  they  must  not  think  anything  about  their  sleep. 

This  advice  given  alone  is  very  rarely  followed  by  any  immediate 
result,  but  if  the  patient  has  the  courage  to  force  himself  to  follow 
this  prescription  for  a  sufficient  length  of  time,  and  if  he  will  be  con- 
tent to  wait  for  some  weeks,  it  may  have  a  favorable  result,  and  then 
again  it  may  happen  that  it  will  be  inefficacious. 


THERAPY  OF  FUNCTIONAL  IVIANIFE STATIONS.        363 

One  should  then  try,  if  we  may  use  the  expression,  to  throw  the 
patient's  habits  off  their  track.  In  order  to  accomplish  this,  he  must 
be  made  to  go  to  bed  at  all  sorts  of  hours,  and  his  regular  hours  of  sleep 
encroached  upon  in  different  ways.  If,  for  example,  he  is  accustomed  to 
fall  asleep  at  about  eleven  o'clock  at  night  and  wake  at  one  in  the  morn- 
ing, he  must  be  told  to  go  to  bed  at  times  other  than  those  of  his  usual 
habit. 

If,  on  the  contrary,  we  have  to  deal  with  a  patient  who  does  not 
sleep  until  far  on  in  the  night,  one  would  go  to  work  differently.  For 
example,  if  the  patient  sleeps  between  four  and  six  o'clock,  one  would 
waken  him  after  he  had  slept  a  half  an  hour  or  an  hour.  It  might 
then  happen  that  he  would  faU  asleep  again,  and  perhaps  sleep  for  a 
very  long  time. 

Even  in  this  way  success  is  not  always  certain.  Certain  phy- 
sicians in  these  cases  have  recourse  to  hypnotics,  and  think  to  take 
advantage  of  their  action  in  such  a  way  as  to  cause  sleep  before  the 
usual  hour  or  to  prolong  it  by  this  means.  They  then  prescribe  for 
the  patient  veronal,  trional,  or  sulphonal.  But  the  chief  thing  is  not 
to  give  an  h^^notic  of  a  given  dose  at  a  given  time.  Still  further  is  it 
necessary  that  the  patient  should  not  form  a  habit  of  being  able  to  go 
to  sleep  only  by  such  an  artificial  aid,  and  that  one  should  not  be 
obliged  to  prolong  indefinitely  the  use  of  any  drug  which  will  finally 
lose  its  effect.  In  this  lies  the  danger  of  such  a  proceeding,  and  it  is 
for  this  reason  that  we  do  not  recommend  it,  having  too  often  seen  in 
our  practice  subjects  who  for  years  have  not  been  able  to  sleep  without 
the  aid  of  drugs,  of  which  they  have  naturally  grown  to  take  larger 
and  larger  quantities.  We  much  prefer  in  these  cases  of  rebellious 
insomnia  to  advise  sponging  off  with  tepid  water,  or  prolonged  tepid 
baths,  from  which  treatment  we  have  more  than  once  had  very  good 
results. 

At  all  events,  we  think  it  extremely  dangerous  in  dealing  with  such 
insomnias  to  practise  such  devices  as  obliging  the  patients  to  take 
violent  and  long  physical  exercise,  with  the  end  in  view  of  tiring  them 
out,  and  fairly  forcing  them,  as  it  were,  to  sleep.  As  a  matter  of 
fact,  the  effect  which  is  most  often  produced  is,  that  the  patient  reacts 
to  his  fatigue  by  absolute  insomnia,  and  that  by  such  practices  he 
loses  what  little  sleep  he  had,  which,  although  it  may  not  have  been 
sufficient,  yet  was  comparatively  restful. 

Quite  to  the  contrary,  in  very  obstinate  eases,  we  think  that  it  is 
much  better  to  have  recourse  to  absolute  rest,  even  to  isolation,  which 
has  sometimes  succeeded  in  overcoming  insomnias  which  hitherto  had 
resisted  all  the  therapeutic  measures  which  had  been  employed. 

The  treatment  of  patients  whose  insomnia  is  of  phobic  origin  is  also 
not  without  some  difficulties.  If  there  are  some  subjects  who,  for  fear 
of  not  getting  enough  sleep,  get  to  the  point  where  they  sleep  more 


364      THE  TREATMENT  OF  PSYCHONEUROSES. 

than  they  need  to,  and  whose  insomnia  is,  as  a  matter  of  fact,  purely- 
subjective,  there  are  others  whose  insomnia  is  absolutely  real.  Through 
their  restlessness,  and  the  irritated  state  that  they  work  themselves  into 
while  waiting  to  fall  asleep,  they  are  constantly  repelling  the  sleep 
which  only  asks  to  be  allowed  to  come.  The  rôle  of  the  physician  must 
evidently  be  to  reassure  his  patient,  and  to  explain  to  him  the  causes 
of  his  insomnia,  which  in  themselves  have  nothing  to  do  with  sleep. 
But  that  is  not  always  enough,  and  the  patient  often  clings  to  his  fear 
of  insomnia  so  strongly  that  the  bad  habits  which  he  has  formed  are 
frequently  kept  up  in  spite  of  all  psychotherapeutic  intervention. 

The  treatment  which  consists  in  requiring  the  patient  to  lie  per- 
fectly still  in  bed  while  waiting  for  sleep  to  come,  or  of  requiring  him 
to  employ  some  mechanical  device,  such  as  counting  indefinitely  in  a  low 
voice,  so  as  to  permit  sleep  to  steal  upon  him  unawares,  etc.,  seems  to 
us  poor,  for  it  only  keeps  the  patient's  mind  either  upon  his  craving 
for  sleep  or  (what  amounts  to  the  same  thing)  upon  the  fear  that  it 
will  not  come  to  him. 

The  therapy  for  this  symptom  must  be  handled  a  little  more  subtly. 
If  simple  therapeutic  action  has  had  no  results,  or  if,  in  other  words,  in 
spite  of  all  one  has  said  to  him,  the  patient  cannot  get  to  the  point  of  pay- 
ing no  attention  to  his  theoretic  or  real  insomnia,  one  must  resort  to  some 
more  circuitous  method. 

Here  is  one  method  which  has  sometimes  succeeded  for  us.  After 
having  made  our  patient  understand  that  the  restless  condition  into 
w^hich  he  worked  himself  was  the  only  cause  of  his  insomnia,  we  have 
asked  him  to  go  to  bed  at  some  time  before  his  usual  hour,  telling  him 
not  to  try  to  go  to  sleep  then,  but  simply  to  give  himself  time  to 
allow  the  excitement  caused  by  his  day  to  quiet  down.  He  may  get  up, 
we  tell  him,  half  an  hour  later,  and  not  go  to  bed  again  until  his 
accustomed  time.  Now,  during  this  period,  when  the  patient,  thinking 
that  he  is  simply  resting,  is  not  trying  to  go  to  sleep,  it  frequently 
happens  that  he  falls  asleep  and  does  not  wake  up  until  morning.  From 
that  time  on,  being  reassured,  he  will  go  to  sleep  normally. 

In  fact,  in  such  cases  the  methods  of  distraction  are  those  which  are 
most  likely  to  succeed.  The  physician  will  have  to  exercise  all  the 
ingenuity  of  which  he  is  capable  to  make  them  fit  the  particular  circum- 
stances. But  here  again  he  will  fall  into  a  series  of  therapeutic  errors 
if  he  thinks  that  by  tiring  his  patient  physically,  or  putting  him  through 
a  severe  hydrotherapeutic  treatment,  he  will  get  a  good  result.  The 
insomnia  will,  as  a  rule,  only  become  more  pronounced,  and  will  have 
a  natural  cause,  for  we  know  that  excessive  fatigue  is  apt,  even  in  many 
people  who  are  perfectly  well,  to  drive  away  sleep. 

Now  that  we  are  ready  to  take  up  the  insomnias  which  arise  from 
the  fact  that  the  patient,  whatever  he  may  do,  is  pursued  by  an  obsessive 
preoccupation,  or  those  which  encourage  the  voluntary  persistence  of 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.         365 

such  preoccupations  in  consciousness,  the  therapy  is  quite  a  different 
thing.  The  insomnia  is  only  a  secondary  phenomenon,  and  its  disap- 
pearance will  be  brought  about  by  the  disappearance  of  the  causes  which 
created  it. 

Rest,  isolation,  and  overfeeding,  which  permit  the  subject  to  get 
hold  of  himself  more  easily,  and  which  cause  the  disappearance  of  all 
those  troubles  which  emotional  fatigue,  itself  the  cause  of  insomnia,  has 
brought  about,  with  the  addition  of  psychotherapy,  with  its  recon- 
structive and  liberating  action,  will  be  enough,  without  resorting  to 
any  indirect  processes,  to  bring  back  sleep  to  such  patients,  who  some- 
times have  been  without  it  for  a  long  time.  All  those  subjects  who  do 
not  sleep  because  they  are  thinking  about  things  are  much  more  pre- 
occupied by  their  thoughts  themselves  than  by  the  insomnia  which 
follows  them. 

In  the  great  majority  of  cases,  such  subjects  have  no  phobias  con- 
cerning sleep.  However,  it  may  happen  that  the  mechanisms  will  com- 
bine, and  that  even  in  these  cases  methods  of  distraction  and  even 
those  of  re-education  may  be  found  useful.  As  a  matter  of  fact  this 
is  rather  rare.  It  is  necessary,  however,  to  point  out  the  possible 
existence  of  such  an  association. 

As  for  the  functional  disturbances  of  sleep,  restless  sleep,  sleep  which 
leaves  one  still  tired,  etc.,  which  may  result  either  from  a  pure  sugges- 
tion, or  in  the  case  of  a  patient  who  is  much  preoccupied  by  reason  of 
the  repeated  invasions  of  the  psychological  automatism  into  the  domain 
of  consciousness,  their  treatment  evidently  requires  general  psycho- 
therapeutic methods,  and  has  no  special  indications. 

B.  Headache. — The  headache  of  neurasthenics  has  a  double  origin. 
Often  it  is  a  question  of  a  true  headache, — a  headache  due  to  fatigue, 
which  disappears  spontaneously  with  rest  in  isolation,  or  even  sometimes 
by  the  simple  action  of  rest  alone,  under  the  conditions,  it  must  be 
understood,  that  emotional  fatigue  is  not  kept  up  by  any  persistent 
preoccupation.  This  first  form  of  neurasthenic  headache  yields  to  the 
action  of  psychotherapy  combined  with  its  supplementary  adjuncts. 

Under  other  circumstances,  the  headache  is  only  a  subjective  phenom- 
enon, which  by  a  sort  of  instinctive  logic  the  patient  associates  with  all 
his  psychic  weaknesses,  whether  real  or  theoretical.  He  will  translate 
under  the  form  of  headache  the  impossibility  which  he  feels,  for  example, 
of  doing  any  work.  It  is  along  the  same  line  of  reasoning,  or  perhaps 
more  conscious,  that  so  many  young  people  or  young  girls,  make  a  head- 
ache their  pretext  to  excuse  themselves  from  some  duty  which  they  had 
not  performed  or  which  had  not  been  finished.  Between  an  impression 
of  helplessness  and  an  impression  of  pain,  the  subjective  margin  is  not 
very  great, — not  great  enough  in  any  case  to  prevent  neurasthenics  from 
quickly  taking  advantage  of  it. 


366      THE  TREATMENT  OF  PSYCHONEUROSES. 

It  goes  without  saying  that,  therapeutically  speaking,  the  fate  of 
this  kind  of  headache  is  directly  associated  with  the  diminution  or 
the  disappearance  of  the  psychic  asthenia  with  which  it  is  associated. 
Psychotherapy  is  all  that  is  needed  here,  and  in  itself  it  will  be  sufficient. 

C.  Psychic  Disturbances. — The  disturbances  of  psychological 
functions  which  we  observed  in  neurasthenics  spring,  as  we  have  seen, 
from  a  certain  number  of  different  mechanisms.  True  psychic  asthenia, 
due  to  emotional  fatigue;  false  psychic  asthenia,  occurring  more  often 
in  patients  who  are  preoccupied  and  who  cannot  succeed  in  turning 
their  attention  to  outside  things,  or  who  are  put  to  considerable  strain 
to  obtain  such  a  result  ;  phobic  symptoms  or  obsessions  :  these,  in  short, 
constitute  the  disturbances  which  are  most  frequently  observed. 

True  psychic  asthenia,  due  to  fatigue,  yields  to  rest,  whether  or  not 
accompanied  by  isolation.  It  ought  to  be  relieved  in  a  comparatively 
short  time,  and  we  have  already  indicated  the  way  in  which  one  can 
tell  about  how  much  time  must  be  allowed  for  a  curative  rest. 

False  psychic  asthenia  may  follow  a  true  asthenia.  It  occurs  in 
patients  who  during  a  period  of  fatigue  have  become  absolutely  con- 
vinced of  their  mental  weakness,  and  who  are  so  convinced  of  their 
inability  that  they  refuse  to  make  any  efforts,  which,  from  the  start, 
they  think  would  be  quite  useless.  False  asthenia  may  also  be  established 
alone  as  a  result  of  the  patient's  really  finding  considerable  difficulty 
in  performing  any  intellectual  work.  These  difficulties  have  nothing  to 
do  with  any  lack  or  psychic  deficiency  whatever,  but  are  only  the 
natural  expression  of  the  impossibility  which  a  preoccupied  patient  will 
find  of  fixing  his  attention  on  anything  but  that  which  is  preoccupying 
him. 

Evidently,  in  the  presence  of  such  troubles,  general  psychotherapy 
will  be  all  that  is  required.  The  moment  the  preoccupations  disappear, 
the  symptoms  which  were  secondary  to  them  will  have  every  chance  of 
disappearing  also.  It  is  no  less  true  that  attention  is  a  psychological 
function  which  educates  itself,  and  which  to  a  certain  extent,  if  it  is 
not  used,  can  be  brought  into  play  later  only  with  some  difficulty.  This 
is  an  idea  which  the  physician  ought  continually  to  bear  in  mind,  for 
it  will  often  be  necessary  for  him  progressively  to  re-educate  the  atten- 
tion of  his  patient. 

There  is  no  lack  of  means  of  accomplishing  this;  from  simple 
arithmetical  calculations  to  the  most  complex  problems,  there  is  a  whole 
series  of  gradations  in  the  attention  necessary  to  solve  them.  One  can 
employ  these  if  the  patient  who  is  to  be  re-educated  has  any  idea  of 
mathematics. 

The  habit  of  making  a  summary  of  what  one  has  read,  and  increas- 
ing the  amount  and  the  difficulty  of  the  subject,  is  something  which 
is  possible  for   any  patient  to   do.     Along  these    lines    a    thousand 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.         367 

ways  may  be  found  in  requiring  patients  to  sustain  their  attention  more 
and  more  until  they  themselves  recognize  the  fact  that  they  are  capable 
of  normal  work.  Some  precautions,  however,  must  be  observed.  For 
instance,  it  is  not  wise  at  the  start  to  ask  a  subject  who  is  still  con- 
vinced of  his  helplessness,  and  whose  outlook  on  life  is  pessimistic,  to 
fasten  his  attention  on  any  intellectual  work  which  is  at  all  like  that 
which  he  was  used  to  doing  in  his  normal  state.  Under  these  con- 
ditions there  would  be  too  great  a  chance  that  the  patient  by  comparison 
with  his  former  facility  would  exaggerate  his  actual  incapacity.  Also 
in  laying  out  the  daily  amount  of  intellectual  work  to  be  accomplished, 
the  amount  must  be  carefully  limited  and  planned  in  such  a  way 
that  the  impression  of  fatigue  may  not  arise  and  bring  with  it  a  whole 
series  of  depressing  ideas.  It  seems  to  us  that  the  best  way  is  to  act 
exactly  as  in  the  treatment  of  psychic  asthenia,  to  which,  mutatis 
mutandis,  and  to  avoid  too  much  repetition,  we  refer  the  reader. 

How  should  one  act  in  the  presence  of  a  patient  who  is  affected  by 
various  phobic  symptoms?  These,  from  the  therapeutic  point  of  view,, 
are  of  two  kinds.  Sometimes  the  phobia  refers  to  something  objective^ 
and  is  in  consequence,  such  as  is  the  case  with  agoraphobia, — \ve  refer 
here  to  that  of  the  neurasthenic,  and  not  of  the  major  psychasthenic, — 
susceptible  to  re-education.  To  reassure  the  patient,  show  him  experi- 
mentally that  he  may  be  master  of  his  phobia  by  progressively  making 
him  accustomed  to  the  various  elements  of  which  it  is  composed.  This 
is  the  rule  to  follow  in  such  cases.  It  means  practically  that  one  must 
therapeutically  organize  and  direct  the  struggle  which  the  patient  must 
make  against  his  phobia. 

But  when  it  is  a  case  of  phobias  which  depend  purely  upon  ideas, 
such  as  the  phobia  of  suicide  or  of  doing  harm  to  some  one  else,  where 
any  objective  re-education  is  quite  evidently  impossible,  how  can  one 
then  proceed?  This  is  an  important  matter,  for  these  phobic  symptoms 
are  bound  up  with  intense  emotional  states,  and  it  is  most  essential,  in 
order  that  a  neurasthenic  should  be  cured,  that  they  should  disappear 
at  the  same  time  as  the  emotion,  which  can  be  (as  we  have  seen)  both 
the  cause  and  the  consequence  at  one  and  the  same  time. 

Something  is  already  accomplished  when  the  patient  has  been  re- 
assured and  shown  the  nature  of  the  symptom  from  which  he  is  suffer- 
ing, and  the  difference  established  that  there  is  between  this  symp- 
tom and  the  impulsion  which  is  the  only  thing  that  could  lead  to 
suicide  or  crime.  By  such  steps  one  will  get  to  the  point  where  he  will 
be  convinced  that  he  is  running  no  risk,  and  where  he  will  assure  him- 
self that  he  will  never  commit  suicide  and  never  do  any  harm  to  any 
one  unless  voluntarily  and  for  some  given  reason.  He  will  take  less 
precaution,  for  instance,  to  avoid  passing  an  open  window  or  seeing  or 
touching  fire-arms.  He  cannot  help  ha\ang  an  involuntary  appre- 
hension, and  here  we  are  in  the  domain  of  the  subconscious  and  psycho- 


368      THE  TREATMENT  OF  PSYCHONEUROSES. 

logical  automatism.  It  is  evident,  that,  every  time  the  memory  of  his 
phobic  symptom  is  called  forth  by  the  association  of  ideas,  it  will 
produce  in  the  patient's  mind  a  very  disagreeable  impression,  accom- 
panied by  this  feeling  of  apprehension,  which  is  a  minor  type  of 
phobia,  purely  involuntary  and  quite  subconscious,  against  which  the 
patient  may  struggle,  but  whose  apparition  is  none  the  less  quite  in- 
dependent of  his  will. 

It  seems  to  us,  that,  when  we  have  to  deal  with  symptoms  which 
bring  the  psychological  automatism  into  play,  we  must  take  into  con- 
sideration the  condition  which  attends  its  most  frequent  and  most  in- 
tense occurrence.  It  is  very  certain  that  any  idea  whatsoever  will  have 
all  the  more  chance  of  crossing  the  threshold  of  consciousness  if  it 
has  been  recently  associated  with  a  great  number  of  facts  or  things. 
In  the  presence,  therefore,  of  phobic  symptoms  of  the  kind  which  we 
have  just  been  considering,  we  do  not  always  advise  starting  out  to 
make  a  sort  of  experimental  struggle  against  the  phobia.  If  we  are  in 
the  room  of  a  patient  who  is  afraid  that  he  will  sometime  throw  himself 
out  of  the  window,  if  we  open  the  casement  wide  to  prove  to  him  how 
certain  it  is  that  he  runs  no  risk,  and  to  base  our  argument  on  the  very 
fact  that  instead  of  throwing  himself  toward  the  window  he  draws  back 
into  the  room,  it  seems  to  us  that  such  a  proceeding  is  very  good  to 
try  once.  Nevertheless,  we  would  not  think  it  wise,  especially  if  one 
could  not  have  continuous  psychotherapy  going  on  at  the  same  time, 
to  ask  the  patient  at  the  start  to  sleep  with  his  windows  wide  open; 
nor  would  we  advise  those  who  are  afraid  of  naked  weapons  or  fire- 
arms always  to  have  a  set  of  razors  or  a  six-barrelled  revolver  and  a 
number  of  guns  lying  about.  Such  methods  may  give  excellent  results. 
They  may  cause  the  almost  instantaneous  disappearance  of  phobias, 
sometimes  of  long  standing,  by  the  feeling  of  security  which  they  give 
to  the  patients.  But  they  may  also  encourage  a  state  of  unintermittent 
emotionalism,  and,  by  multiplying  the  association  of  ideas,  work  the 
phobia  into  a  much  more  continuous  though  possibly  less  violent  con- 
dition. It  has  often  seemed  to  us  that  it  was  more  prudent  at  first, 
and  sometimes  for  a  considerable  time,  to  be  silent  concerning  these 
phobic  symptoms.  It  seems  to  us  that  it  is  often  more  necessary  to 
teach  the  patient  how  to  forget  than  how  to  struggle.  To  withdraw  the 
patient  from  his  daily  surroundings  both  of  people  and  of  things  in 
which  the  phobia  was  started,  to  avoid  everything  that  may  recall  it 
to  him,  to  avoid  even  mentioning  it,  in  short  to  get  as  far  away  from  it 
as  possible,  is  perhaps  a  cowardly  proceeding,  but  one  which,  neverthe- 
less, often  succeeds  very  well,  when  the  patient,  it  is  understood,  has 
been  previously  reassured  concerning  his  condition. 

When  new  ideas  have  been  bom,  and  a  different  association  of  ideas 
has  come,  so  to  speak,  to  overlay  and  blot  out  the  old  phobic  asso- 
ciations, they  will  be  called  forth  much  more  faintly.     The  struggle 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.         369 

will  then  be,  but  only  then,  comparatively  easy  for  the  patient,  and 
will  take  place  without  the  aid  of  any  emotional  phenomena,  which  are 
often  dangerous  because  they  are  depressing. 

As  to  the  disturbance  of  the  v/ill  which,  according  to  certain  authors, 
is  characteristic  of  neurasthenia,  we  do  not  believe  in  it.  Quite  evi- 
dently, in  people  who  are  greatly  fatigued  by  emotion,  the  will  is 
secondarily  deficient,  as  it  might  be  in  any  one  who  was  ill  or  con- 
valescing; but  it  is  found  to  be  virtually  intact  after  sufficient  rest. 
The  thing  that  is  lacking  in  the  neurasthenic  is  not,  as  we  have  so 
repeatedly  said,  his  will,  but  it  is  a  point  of  application  that  will  make 
his  will  persistent.  We  have  laid  sufficient  stress  upon  this  in  our 
chapter  on  the  general  psychotherapy  of  the  moral  and  mental  con- 
dition of  the  neurasthenic,  on  the  necessity  there  is  for  the  physician 
to  redirect  his  patient's  mind  for  the  very  purpose  of  furnishing  his 
will  with  a  point  of  application.  It  does  not  seem  to  us  necessary  to 
return  to  the  subject. 

V.  Special  Therapy  of  Hysterical  Symptoms. 

Although  contrary  to  the  descriptive  order  which  we  have  adopted 
in  the  first  part  of  this  work,  we  have  thought  that  it  would  be  in- 
teresting, from  the  point  of  view  of  the  therapeutic  study,  to  treat  all 
the  hysterical  symptoms  together,  because,  as  a  matter  of  fact,  some 
very  general  lines  of  treatment  are  applicable  to  all  of  them  while  at 
the  same  time  some  require  very  special  treatment, — very  special  be- 
cause they  apply  only  to  hysterical  symptoms,  and  very  general  also 
because  they  apply  to  all  these  symptoms. 

This  is  because  hysteria  is  therapeutically,  as  a  matter  of  fact, 
composed  of  two  things,  a  mental  and  moral  condition  on  the  one  hand 
and  symptoms  on  the  other.  Although  the  moral  condition  of  the 
hysteric,  as  well  as  his  mental  condition,  may  be  very  directly  helped 
by  the  psychotherapy  of  persuasion,  we  cannot  apply  the  same  treat- 
ment with  any  success  to  the  sjonptoms.  A  person  who  is  preoccupied 
or  who  has  some  localized  phobia  can  be  reasoned  with,  for  these  phenom- 
ena have  a  positive  psychological  reason  for  being;  but  how  can  we 
reason  with  a  person  whose  symptom,  like  that  of  any  hysterical  symp- 
tom, is  merely  a  minus  sign,  a  psychological  lack  of  interest,  if  one 
might  so  call  it,  concerning  the  function  or  the  organ  which  is  affected  ? 
One  could  not,  therefore,  properly  speak  of  persuasion  as  having  any 
effect  in  such  cases,  but  we  might  better  use  the  words  ''act  of  re- 
calling," or  "re-education,"  to  describe  the  actions  to  which  we  refer. 
It  must,  nevertheless,  be  understood  that  all  that  we  have  said  concern- 
ing the  action  of  sthenic  emotions  in  the  treatment  of  the  psycho- 
neuroses  is  true  for  hysterical  symptoms,  and  that  the  best  action  of 
recall,  the  very  condition  under  which  re-evocation  is  possible,  will  be 
21 


370      THE  TREATMENT  OF  PSYCHONEUROSES. 

the  disappearance,  under  the  action  of  sthenic  emotions,  of  all  those 
ideas  and  emotional  memories  of  every  kind  which  could  be  continued 
by  inhibition. 

But,  outside  of  the  very  special  rôle  of  sthenic  emotion, — which, 
however,  cannot  always  be  voluntarily  produced, — it  has  always  seemed 
to  us  that  the  therapy  of  all  hysterical  symptoms  might  be  summed 
up  in  this  formula — re-education  in  isolation. 

If  it  is  a  question  of  contractures,  of  paralysis,  or  of  disturbance 
of  general  or  special  sensibilities,  there  is  no  treatment  for  the  hysterical 
symptom  other  than  isolation.  It  has  been  experimentally  proved  as  a 
fact,  and  a  fact  which  must  be  admitted,  even  though  the  reason  for  it 
often  escapes  us.  It  may  be  that  isolation  acts  by  suppressing  all  out- 
side causes  for  emotion,  or  that  it  acts  by  encouraging  the  patient  to 
forget  the  inhibitive  emotional  cause,  or  it  may  be  that  the  action  is 
due  rather  to  the  concentration  of  the  patient's  psychism,  which  when 
not  in  isolation  is  readily  dissipated,  but  which  in  solitude  is  concen- 
trated sufficiently  to  recall  the  forgotten  functions.  It  may  be  that 
isolation  exercises  an  action  of  constraint  upon  patients  whose  symp- 
toms may  in  some  cases,  though  certainly  not  in  all,  have  arisen  from 
suggestion,  and  that  in  order  to  be  free  from  their  solitary  confinement 
they  are  willing  by  auto-suggestion  to  throw  off  their  symptoms.  It 
is  quite  certain  that  with  patients  whose  character  is  difficult  to  manage 
and  with  children  and  young  people  this  mechanism  may  be  very  fre- 
quently used.  Isolation  then  acts  in  the  same  way  that  a  more  or  less 
strong  emotion  will  act,  producing  the  effect  of  a  moral  shock  upon  the 
patient,  which  is  capable  of  *' letting  loose"  his  constraint.  When  in 
hysteria,  for  example,  one  sees  the  attacks  which  have  been  uninter- 
rupted, such  as  contracture  or  paralysis,  disappearing  within  twenty- 
four  or  forty-eight  hours,  it  is  perfectly  evident  that  isolation  acts  as 
a  moral  shock  would  in  such  cases. 

At  other  times  it  is  possible  that  isolation  has  an  element  of  con- 
viction which  acts  upon  the  patient's  mind,  and  that  in  this  way  the 
idea  becomes  more  firmly  fixed  in  the  patient  that  he  can  be  cured  and 
must  be  cured,  and  that  he  will  not  be  restored  to  liberty  until  the 
symptoms  which  have  troubled  him  have  disappeared.  The  one  thing 
that  we  must  not  forget  is  that  in  such  cases  isolation  is  an  imperative 
necessity,  and  that,  whatever  may  be  the  way  in  which  it  acts,  its  action 
is  at  least  favorable,  and  generally  sufficient. 

The  second  element  of  treatment  consists  in  re-education.  It  is  by 
means  of  re-education  that  all  the  special  psychotherapeutic  action  has 
its  effect.  This  re-education  includes  two  elements,  according  to  whether 
the  loss  of  voluntary  action  is  associated  or  not  with  the  persistence  of 
automatic  action.  Here,  for  instance,  is  a  subject  who  is  suffering  from 
an  hysterical  hemiplegia, — ^that  is  to  say,  he  is  incapable  of  any  volun- 
tary motor  action  in  one  half  of  his  body.    The  process  of  re-educating 


THERAPY  OF  FUNCTIONAL  MANIFESTATIONS.        371 

him  consists  simply  in  asking  him  to  bring  his  will  to  bear  upon  his 
voluntary  movements,  making  an  effort  to  perform  some  of  them  par- 
tially at  first,  and  then  to  make  them  more  completely.  Another 
patient  is  anaesthetic.  Re-education  in  this  case  will  teach  the  patient 
to  fix  his  attention  on  his  sensibility  until  the  mental  representations 
will  again  correspond  to  the  stimuli. 

Re-education  in  eases  of  this  kind  is  only  an  act  of  recalling  or  an 
act  of  reconstitution. 

Here,  on  the  other  hand,  is  a  patient  suffering  from  an  hysterical 
contracture.  As  far  as  phenomena  of  consciousness  and  will  are  con- 
cerned, he  is  practically  paralytic,  as  he  has  lost  all  capacity  for 
voluntary  movement.  His  contracture  is  only  due  to  the  persistence  of 
an  automatic  action,  which,  as  we  have  seen,  is  practically  but  the 
continuation  of  the  impulsion  received  at  the  moment  when  the  dis- 
location was  established.  Here  the  action  of  re-education  will  be  two- 
fold :  it  will  be  passive  in  a  large  degree,  and  will  consist  of  appropriate 
movements  to  break  the  existing  contracture,  while,  on  the  other  hand, 
the  patient  will  be  asked  to  put  forth  his  will  directly  to  produce  the 
movements  in  the  contracted  limb. 

As  for  the  way  in  which  this  re-educative  will  can  put  forth  its 
solicitations,  it  ought  to  be  directed  toward  opposing  the  convictions 
of  helplessness  which  the  patients  have  experienced,  an  inverse  con- 
viction which  expresses  itself  in  affirmations  and  authoritative  deeds. 
One  should  not  hesitate  to  encourage  these  solicitations  of  the  will  in 
some  practical  form.  The  patients  who  do  not  make  any  progress 
should  be  punished  in  some  way,  and  those  who  do  improve  should  be 
rewarded.  The  gradation  in  more  or  less  complete  or  more  or  less 
severe  isolation  will  give  steps  in  this  ladder  of  punishments  and 
rewards,  which  may  be  used  with  advantage.  The  permission  to  receive 
letters,  and  visits,  or  the  privilege  of  going  out  for  a  walk  if  one 
wishes,  etc.,  will  constitute,  for  example,  motive  influences  which  will 
often  have  much  more  effect  than  the  most  subtle  persuasion  in  de- 
termining the  patient's  efforts. 

What. we  have  called  ''punishments"  must  be  limited  to  this,  and 
this  only.  We  absolutely  disapprove  of  all  processes  of  intimidation, 
which  are  more  or  less  brutal,  in  the  treatment  of  hysterical  symp- 
toms. The  method  which  we  employ  is  that  of  absolute  firmness,  under 
which  the  patient,  however,  can  see  that  we  have  his  interest  at  heart. 
It  is  what  we  might  describe  as  an  iron  hand  gloved  in  velvet,  and, 
according  to  our  way  of  thinking,  it  is  the  only  thing  which  is  truly 
logical,  for  we  have  been  convinced  for  a  long  time  that  an  hysteric  is 
not  a  person  who  imagines  himself  ill  for  the  fun  of  the  thing,  but  that 
he  is  quite  as  much  to  be  pitied  as  the  neurasthenic. 

There  are  no  hysterical  symptoms  which  will  hold  out  against  this 
therapy,  whose  details  we  shall  not  dwell  upon,  because  what  we  have 


372      THE  TREATMENT  OF  PSYCHONEUROSES. 

just  said  seems  to  us  to  be  sufficient  to  direct  re-education  according  to 
each  particular  case.  But  it  must  not  be  imagined  that,  because  it 
happens  so  frequently,  the  cure  always  takes  place  rapidly.  In  a  great 
many  cases  one  cannot  predict  the  length  of  time  that  will  be  re- 
quired for  the  treatment.  There  does  not  even  seem  to  be  any  definite 
relation  between  the  long  standing  of  the  symptoms  and  the  time  that 
will  be  required  to  make  them  disappear.  But  in  a  general  way  we 
might  say  that  the  sjrmptom  is  either  cured  very  quickly  or  it  is  cured 
very  slowly.  Intermediate  cases  are,  as  a  matter  of  fact,  rather  rare. 
While  the  treatment  of  the  symptoms  is  being  carried  on,  the  strongest 
pedagogic  influence  upon  the  mental  condition  which  has  allowed  it  to 
become  established  should  be  put  forth.  This  action  ought  always  to  be 
prolonged,  even  after  the  symptom  has  disappeared.  For  in  it  lies  the 
prophylactic  therapy  which  we  shall  refer  to  further  on. 


CHAPTER  XXVI. 

PSYCHOTHERAPY  AS  REGARDED  BY  PHYSICIANS  AND  PATIENTS. 

We  have  now  taken  up  the  majority  of  functional  manifestations 
which  seem  to  us  to  require  some  special  treatment.  In  one  case  it  is 
struggle  and  endeavor,  in  another  it  is  psychological  forgetfulness,  in 
still  another  it  is  distraction  in  the  etymological  sense  of  the  word,  that 
is  changing  the  course  of  ideas.  Elsewhere  it  is  the  re-education  of  the 
patient,  sometimes  voluntary  and  sometimes  carried  on  without  the 
patient's  knowledge,  which  must  be  thought  out  and  directed  according 
to  each  particular  case.  One  sees  how  great  a  diversity  there  may  be 
in  psychotherapeutic  work.  When  people  say  that  psychotherapy  has 
always  existed,  and  when  physicians  state — remembering  how  they  are 
wont  to  comfort  and  encourage  their  patients  by  patting  them  affection- 
ately on  the  back — that  they  have  always  practised  it,  we  feel  that 
they  have  not  taken  the  subject  very  seriously.  Undoubtedly  it  is 
psychotherapy,  and  one  of  the  best  forms  of  psychotherapy,  to  take  an 
interest  in  the  moral  welfare  of  a  patient.  But  it  is  not  enough  to  be 
interested  in  it  as  a  whole,  or  en  masse,  if  we  might  so  express  it;  one 
must  concern  one's  self  with  every  detail,  with  its  intimate  and  some- 
times very  remote  causes,  and  chiefly  in  all  the  different  consequences 
which  the  moral  condition  of  a  patient  is  apt  to  result  in  under  emotion 
as  well,  and,  above  all,  in  all  the  different  consequences  which  are  apt 
to  occur  to  the  patient's  moral  condition  when  in  a  state  of  emotion. 

We  shall  have  finished  with  our  therapeutic  study  when  we  have 
pointed  out  a  few  of  the  particular  ways  in  which  psychotherapy  is 
indicated  to  the  physicians  who  practise  it,  or  to  the  patients  who  put 
themselves  under  such  treatment. 

In  order  to  practise  good  psychotherapy,  it  is  absolutely  necessary 
to  know  one 's  patients  through  and  through  in  every  part  of  their 
personality.  This  is  a  necessary  condition,  but  it  alone  is  not  enough. 
It  is  also  necessary  to  know  one's  self,  and  to  realize  whether  one  has 
sufficient  tact  and  authority  to  handle  a  certain  patient,  and  to  what 
degree  one  is  capable  of  inspiring  his  confidence. 

This  is  because,  although  the  psychotherapeutic  result  which  is 
sought  for  represents  a  constant  factor,  the  various  methods  of  psychic 
action  are  variable  factors  depending  upon  the  physicians  and  upon 
the  patients.  Given  a  certain  symptomatic  ensemble,  certain  psycho- 
therapeutic processes  will  be  successful  when  practised  by  a  certain 
physician  on  a  certain  patient,  but  the  same  will  have  no  value  at  all 
if  practised  by  another  physician  on  a  different  patient.  His  age,  his 
position,  his  physique,  and  even  the  tone  of  his  voice  may  lend  an 

373 


374     THE  TREATMENT  OF  PSYCHONEUROSES. 

authority  to  one  physician  which  will  be  wholly  lacking  in  another,  and 
will  permit  him  to  practise  a  very  different  psychotherapy  from  another 
man  who  may  be  obliged  to  confine  himself  to  some  other  methods. 

All  the  preliminary  endeavors  of  the  physician  should  be  to  gain 
his  patientas  confidence,  but  this  confidence  should  in  no  wise  be  forced, 
lest  he  experience  a  rebuff. 

Take,  for  example,  the  act  of  confession,  upon  whose  liberating 
action  we  have  dwelt  at  such  length.  To  try  to  force  the  patient's 
confidence,  and  to  urge  him  to  make  an  absolute  and  unrestrained  con- 
fession, without  having  first  been  able  to  inspire  him  with  a  feeling  of 
sufficient  security,  is  to  run  the  risk  that  the  patient  will  not  wholly 
unbosom  himself.  Later,  if  you  have  succeeded  in  completely  winning 
his  confidence,  it  would  be  apt  to  be  the  case  that,  having  become  en- 
tangled in  his  denials  and  reticences  and  former  fibs,  he  would  not 
like  to  acknowledge  them. 

All  therapeutic  work  which  is  lacking  in  patience  is  apt,  in  some 
way,  to  be  compromised.  This  confidence,  which  a  young  and  inex- 
perienced physician  can  win  only  after  a  long  time,  will  very  often  be 
called  forth  immediately  by  a  physician  who  has  more  presence  and 
authority. 

Take  again,  for  example,  the  assurance  of  cure,  which  is  so  com- 
forting and  strengthening.  It  is  very  certain  that  the  physician  who 
does  not  impress  the  patient  will  not  be  able  to  make  him  see  this 
possibility,  but  that  when  such  a  statement  is  made  by  an  expert  it  will 
be  regarded  as  a  certainty  by  the  patient,  when  he  would  have  con- 
sidered it  merely  as  a  possibility  if  a  less  experienced  man  had  uttered  it. 

Let  us  take,  for  instance,  a  patient  suffering  from  some  functional 
disturbance.  A  physician  would  tell  such  a  subject^  to  pay  no  attention 
to  this  disturbance,  and  to  treat  it  as  though  it  were  of  no  consequence, 
assuring  him  that  it  is  purely  negative  in  its  effect.  He  will  be 
believed  if  he  says  this  with  a  sufficient  tone  of  authority,  and  the 
patient  will  rapidly  get  over  it  without  any  other  treatment,  but  the 
same  patient  would  receive  the  same  advice  with  much  less  conviction 
if  it  were  given  by  a  physician  whom  he  did  not  consider  so  well 
informed. 

Often,  however,  in  order  to  avoid  a  set-back,  one  would  be  obliged 
in  some  particular  case  to  have  recourse  to  methods  which  are  much 
slower  and  more  certain,  such,  for  example,  as  treatment  by  re-education 
or  distraction. 

But  the  authority  which  one  may  enjoy  and  the  confidence  which 
one  can  inspire  are  things  of  an  extremely  personal  nature,  and  cannot 
easily  be  expressed  in  values.  Is  there  any  way  for  a  physician  to 
know  just  how  much  power  he  possesses  in  this  direction,  especially  as 
the  effect  of  such  power  varies  in  different  patients  and  with  individual 
affinities?     It  is  simply  a  question  of  the  way  that  one  impresses  a 


PSYCHOTHERAPY  SEEN  BY  DOCTORS  AND  PATIENTS.  375 

patient,  and  is  purely  a  matter  of  tact.  The  manner  in  which  the 
patient  behaves,  and  in  which  he  gives  his  replies,  the  manner  in  which 
he  listens,  the  nature  of  the  objections  which  he  raises,  his  attitude  of 
doubt  toward  medical  statements,  are  all  just  so  many  elements  which 
enable  one  to  a  very  great  degree  to  determine  just  what  are  the  best 
measures  to  adopt  in  order  to  gain  control  over  a  given  subject.  One 
will  always  succeed  in  inspiring  confidence  in  a  patient  and  acquiring  a 
sufficient  authority  over  him,  under  the  conditions  which  we  have  just 
given;  but  this  does  not  necessarily  happen  immediately,  and  the  con- 
fidence thus  gained  is  liable  to  be  shaken  by  various  influences.  You 
must  know  how  to  feel  and  understand  the  attitude  of  the  patient  him- 
self toward  you.  This  will  reveal  new  psychotherapeutic  needs  in  the 
patient.  To  regain  a  confidence  or  authority  that  has  been  shaken 
requires  a  certain  delicacy  of  touch. 

All  of  which  amounts  to  the  same  thing  as  saying  that  psychotherapy 
cannot  be  practised  unless  the  physician  is  in  perfect  sympathy  with 
his  patient.  When  it  is  a  case  of  the  moral  treatment  or  psychotherapy 
for  functional  symptoms,  this  is  always  an  indispensable  condition. 
This  feeling  of  fellowship  or  sympathy  should  be  perceived  the 
moment  it  is  established,  for  it  is  only  when  it  comes  that  it  is  possible 
to  obtain  a  complete  confession,  and  to  start  in  upon  the  work  of  re- 
orientation in  the  personality.  One  must  also  be  able  to  know  just 
how  far  it  goes,  and  whether  the  patient  is  capable  of  accepting,  for 
certain  of  these  functional  manifestations,  the  conception  which  the 
physician  has  and  which  is  generally  quite  different  from  his  own. 
Tact,  moderation,  and  observation  must  all  come  into  play,  but,  as  a 
matter  of  fact,  it  is  simply  a  question  of  an  impression  which  is  always 
easily  felt  when  this  indispensable  bond  of  sympathy  is  created  between 
the  physician  and  his  patient. 

Although  when  the  physician  is  not  armed  with  sufficient  authority 
he  is  obliged  to  proceed  cautiously  with  all  his  patients,  there  are,  on 
the  other  hand,  subjects  whose  treatment  necessitates  a  certain  man- 
ner of  conduct  particularly  adapted  to  their  cases,  on  the  part  of  all 
physicians.  Although  the  psychotherapeutic  action  may  vary  with  phy- 
sicians, it  varies  still  more  in  connection  with  the  patients,  their  age, 
sex,  characteristics,  education,  and  even  their  religion. 

First  of  all,  age  furnishes  a  certain  number  of  special  indications. 
One  would  not,  as  a  matter  of  course,  dream  of  employing  the  same 
psychotherapeutic  methods  with  an  old  man,  or  a  patient  well  on  in 
years,  as  with  a  young  person  or  a  child. 

There  is  no  doubt  that  in  the  case  of  a  child,  or  even  of  a  youth, 
the  most  profitable  psychotherapeutic  action  may  be  practised  upon  the 
parents,  who  are,  in  the  majority  of  cases,  responsible  for  the  symptoms 
which  their  offspring  display.  Although  the  action  to  be  brought  to 
bear  upon  the  older  people  be  that  of  persuasion  and  reasoning,  in  the 


376      THE  TREATMENT  OF  PSYCHONEUROSES. 

majority  of  cases  that  which  is  appropriate  to  the  various  symptoms 
occurring  in  younger  subjects  is  the  action  of  authority.  Neither  the 
child  nor  the  young  person  is  able  to  reason.  It  is  very  rare  to  find 
that  education,  which  is  nothing  more  than  a  long-continued  suggestion^ 
has  developed  a  critical  spirit  in  them.  What  is  found  in  these  sub- 
jects, on  the  other  hand,  is  a  spirit  of  contradiction,  the  common  reaction 
of  the  weak  and  the  young  to  the  suggestion  of  others.  To  attempt  to 
reason  with  a  child  or  a  young  person  is  to  run  great  risk  of  seeing 
the  symptom  grow  worse,  and,  far  from  being  cured,  to  plunge  them 
into  a  much  more  complex  and  intense  symptomatology.  That  one 
should  take  advantage  of  childish  sentimentalities  is  naturally  to  be 
understood;  a  child  may  be  asked  to  try  to  act  in  this  manner  or  that, 
for  example,  in  order  to  please  his  parents, — ^that  goes  without  saying; 
but  to  explain  to  him  the  why  and  the  wherefore  of  his  symptoms  will 
often  be  to  lose  valuable  time.  Only  one  form  of  therapy  is  called  for 
here.  It  is  that  which  consists  in  using  appropriate  measures  to 
oblige  or  constrain  the  child,  or  youthful  patient,  to  give  up  his 
symptoms.  Isolation  is  often  indicated  in  just  such  cases  as  a  somewhat 
coercive  measure,  and  ought  not  to  be  abandoned  until  the  subject 
makes  up  his  mind  to  give  up  the  various  symptoms  which  he  presents. 
Simple  statements  and  suggestions  while  awake  are,  we  feel,  practically 
the  only  things  that  are  indicated  in  such  cases.  Still,  it  must  be 
understood  that,  among  young  children  who  are  very  emotional,  the 
action  of  sthenic  emotion  should  by  no  means  be  neglected.  But  one 
should  always  be  on  one 's  guard  against  more  or  less  conscious  tendency 
to  simulation,  and  to  more  or  less  marked  auto-  and  hetero-suggestibility 
which  so  frequently  characterizes  the  infantile  mentality.  If  we  may 
be  allowed  the  expression,  children  are  much  more  apt  than  grown 
people  to  lead  their  physician  a  dance,  and  if  the  latter  does  not  take 
this  into  account  the  therapeutic  result  will  often  be  curiously  com- 
promised. 

Precautions  of  the  opposite  nature  must  be  taken  with  self-centred 
old  people  who  are  fixed  in  their  systematizations.  Any  determined 
statement  or  conviction  too  emphatically  expressed  which  is  opposite  to 
their  own  way  of  thinking  is  sometimes  quite  enough  to  destroy  the 
certain  value  of  all  consecutive  psychotherapeutic  treatment.  The  systema- 
tizations of  the  aged  must  be  slowly  and  gradually  penetrated.  At 
least,  it  must  be  understood  if  he  is  a  little  weak,  and  has  at  the  end 
of  the  long  road  of  life  returned  to  an  infantile  stage  in  which,  credulous 
and  suggestible,  he  will  pay  no  attention  to  reasonings  which  he  only 
vaguely  understands,  but  will,  on  the  contrary,  not  be  able  to  stand  out 
against  plain  distinct  statements. 

In  a  general  way  and  without  reference  to  any  particular  cases,  we 
find  we  have  to  treat  patients  of  each  sex  in  a  different  way.  The 
critical  spirit  is  rarely  much  developed  in  woman.    Her  sentimentality. 


PSYCHOTHERAPY  SEEN  BY  DOCTORS  AND  PATIENTS.   377 

however,  is  usually  exaggerated.  The  beauties  of  a  syllogism  and  the 
fine  points  of  a  subtle  or  possibly  specious  argument  will  leave  her 
unmoved;  she  will  perhaps  be  carried  away  by  the  harmorly  of  sound, 
but  rarely  by  the  harmony  of  ideas.  But  to  make  up  for  this,  all  the 
chords  of  sentiment  are  ready  to  vibrate,  and  the  physician  who  does 
not  take  advantage  of  the  fact  and  play  upon  them  will  lose  his  best 
and  surest  mode  of  action.  A  woman  more  than  a  man  needs  repeated 
and  almost  uninterrupted  psychotherapy.  She  is  by  nature  more 
variable.  Her  psychic  conditions  follow  one  another  quickly  and  with- 
out much  coordination.  When  a  man  is  away  from  his  physician  he 
reflects;  a  woman  forgets  much  more  quickly  what  he  has  told  her,  at 
least  if  what  he  has  said  has  not  touched  her  in  the  vital  part  of  her 
sentimentality;  but,  although  in  a  man  the  sentimental  emotion  dis- 
appears very  soon,  to  give  way  to  logical  thought,  in  a  woman,  though 
the  action  of  the  reason  is  somewhat  fugitive,  the  action  of  sentiment 
lasts  a  long  time.  It  is  very  important  to  take  these  ideas  into  con- 
sideration in  practising  psychotherapy. 

Other  indications,  which  are  often  very  important,  may  be  drawn 
from  the  character  of  the  patient, — ^not  his  artificial  character,  or  that 
mask,  one  might  call  it,  which  his  sickness  gives  to  him,  but  his  previous 
character.  The  methods  to  be  employed  with  a  patient  who  has  always 
been  weak  and  cowardly  will  by  no  means  be  suitable  to  a  person  who 
has  hitherto  been  full  of  energy  but  is  temporarily  down.  To  ask  the 
former  to  make  the  same  effort  of  will  that  one  would  demand  of  the 
latter  would  often  be  imprudent.  For  the  latter  it  is  often  enough 
merely  to  point  out  the  way;  but  with  the  feeble  individual,  on  the 
contrary,  we  have  to  guide  his  every  step,  as  he  hesitates  at  trifles,  and 
even  when  he  is  set  upon  the  right  road  he  loses  sight  of  his  destination 
and  sees  nothing  but  the  obstacles  in  the  way. 

There  are  other  elements  of  character  which  are  also  very  essential 
if  one  is  to  succeed  in  directing  the  patient  by  psychotherapy. 

We  have  said  a  great  deal  about  the  liberative  action  of  confession, 
but  it  is  more  or  less  difficult  to  obtain,  not  only  on  account  of  the 
nature  of  the  thing  which  the  patient  may  have  hidden  in  his  heart, 
but  also  on  account  of  the  habit,  which  he  may  or  may  not  have  formed, 
of  wrapping  himself  up  in  an  impenetrable  personality,  which  he  con- 
siders unapproachable.  The  influence  of  education  plays  a  very  weighty 
part  in  matters  of  this  kind,  and  especially  religious  education. 

It  is  a  certain  fact  that  we  keep  during  our  whole  lives  the  mentality 
of  the  religion  in  /which  we  are  brought  up,  whether  we  have  remained 
faithful  to  our  religion  or  not.  This  mentality  is  of  great  importance 
in  the  formation — ^we  might  almost  say  in  the  essential  characteristics 
— of  character,  and,  even  with  a  person  who  has  become  a  freethinker, 
a  monotheist,  or  an  atheist,  it  does  not  require  a  very  long  conversation 
in  order  to  know  what  religious  beliefs  he  formerly  adhered  to. 


378      THE  TREATMENT  OF  PSYCHONEUROSES. 

It  is  by  no  means  our  intention  to  make  any  profession  of  faitli 
whatsoever,  but  this  does  not  hinder  us  from  saying,  that,  from  the 
stand-point  of  physicians,  they  are  obliged  to  recognize  that  it  is  very 
much  more  difficult  to  produce  any  psychotherapeutic  action  upon  a 
Protestant  than  upon  a  Catholic,  and  this,  we  repeat,  is  true  whether 
or  not  the  one  or  the  other  has  remained  faithful  to  the  religious  con- 
ceptions of  his  youth.  The  Catholic,  accustomed  through  confession 
to  disclose  the  most  secret  depths  of  his  intimate  personality,  acts  with 
infinitely  less  reserve  in  the  presence  of  the  physician  than  the  Protestant. 
He  shows  the  psychotherapeutist  nothing  of  that  instinctive  and 
irrational  defiance  of  the  latter,  who  considers  his  personality  inviolable, 
and  who  meets  any  one  who  tries  to  get  at  the  depths  of  his  being  with 
a  stone  wall,  and  often  rather  a  rough  one.  Those  unfortunates  whose 
disease  or  isolation  or  unsympathetic  environment  have  forced  upon 
them  the  solitary  worship  of  their  own  personality  show  a  very  similar 
mentality.  It  is  positively  painful  for  all  temperaments  like  these  to 
acknowledge  their  mistakes,  or  to  even  let  any  one  know  their  con- 
victions or  their  profound  aspirations.  They  raise  a  little  altar  within 
themselves,  the  searching  of  their  conscience  forms  the  sacrifice  of  this 
worship,  but  no  one  else  may  approach  this  altar,  no  one  else  may  be 
present  at  the  sacrifice,  under  pain  of  being  accused  of  persecution  or 
sacrilege.  One  sees  that  in  such  subjects  it  may  be  very  difficult  to 
practise  psychotherapy.  Accustomed  to  examine  and  to  reason  about 
things  that  cannot  be  reasoned  about,  to  know  their  impressions  and 
feelings,  it  is  hard  to  reach  them  in  any  of  the  strong  emotions.  As 
for  reasoning  with  them,  which  in  fact  is  somewhat  difficult  in  all  in- 
dividuals, they  are  so  set  that  they  consider  it  as  an  attack  upon  their 
personal  dignity.  What  precautions  one  has  to  take  with  invalids  like 
•this  !  One  must  proceed  by  insinuations,  by  questions  with  implications  ; 
one  must  guess  what  they  do  not  confess,  get  the  patient  in  such  a  mood 
that  he  will  think  that  he  is  drawing  from  his  own  inner  consciousness 
ideas  which,  as  a  matter  of  fact,  come  to  him  only  at  second  hand; 
and  even  that  is  often  not  enough.  As  a  rule,  all  these  *' shut-in"  per- 
sonalities take  two  or  three  times  as  long  to  cure  as  those  who,  also 
having  their  secret  gardens,  yet  are  more  willing  to  allow  their  con- 
fessor, their  friend,  or  even,  if  the  case  demands  it,  their  physician,  to 
enter  it. 

It  seems  illogical  to  admit  that  there  may  be  neuropaths  who  do  not 
second  the  efforts  of  the  psychotherapeutist,  and  who  accept  with  very 
ill  grace,  which  they  barely  disguise,  all  the  efforts  which  he  makes  upon 
their  behalf.  The  fact  is,  however,  very  rarely  observed.  When  it  is 
the  case  of  minors  isolated  by  the  family  authority,  the  matter  is  of  not 
much  importance,  and  isolation  very  quickly  rights  these  faults  in  their 
characters.    But  when  one  has  to  deal  with  adults,  the  question  of  how 


PSYCHOTHERAPY  SEEN  BY  DOCTORS  AND  PATIENTS.  379 

to  conduct  one's  self  is  much  more  delicate.  It  must  not  be  forgotten 
that  these  are  patients,  and  that  consequently  the  physician's  self- 
respect  is  not  to  be  considered  here.  He  must  not  depart  from  his  usual 
manner,  unless  he  finds  himself  dealing  with  a  subject  who  is  inclined 
to  **take  his  physician's  head  off."  In  such  a  case  two  solutions  are 
possible.  Either  the  patient  can  be  sent  away  and  nothing  more 
done  with  him,  which  is  evidently  not  at  all  humane,  or  else  one  can 
render  him  most  energetic  aid  and  give  him  a  good  sound  rating.  The 
last  proceeding  is  the  one  to  which  we  generally^  have  recourse,  and  it 
has  always  given  excellent  results. 

Finally  it  may  happen,  but  the  thing  is  rather  rare,  that  one  has 
to  do  with  subjects  who  are  so  convinced  of  the  incurability  of  their 
condition  that,  while  they  do  not  show  any  ill  will,  but  are  extremely 
■grateful,  and  even  moved  by  all  the  trouble  that  they  give  to  other 
people,  they  will  none  the  less  make  no  attempt  to  pass  out  of  ''the 
jelly-fish  stage."  In  such  cases  some  strong  emotion  or  some  moral 
shock  which  is  capable  of  vitalizing  them  must  be  found.  We 
have  several  times  succeeded  in  curing  such  patients  by  making  them 
give,  more  or  less  by  force,  their  word  of  honor  to  take  hold  of  them- 
selves and  improve.  This  method  succeeds  chiefly  among  those  psycho- 
neurotics who  have  some  monosymptomatic  form,  and,  we  repeat,  among 
those  subjects  who  have  chiefly  lost  all  hope  of  being  cured.  This  was 
how,  in  a  case  of  complete  aphonia  which  had  lasted  for  four  years, 
coming  on  in  a  woman  thirty  years  of  age,  after  extreme  emotion  due 
to  the  death  of  her  mother,  a  case  in  which  all  psychotherapeutic  methods 
had  come  to  nothing  for  four  months,  the  return  of  her  speech  was 
finally  obtained  by  making  the  patient  sign  an  agreement,  upon  her 
word  of  honor,  to  speak  at  a  fixed  date.  It  is  evident  that  in  this  case 
the  reason  that  this  method  gave  such  a  good  result  was  because  it  was 
addressed  to  a  person  whose  nature,  we  happened  to  know,  was  upright, 
and  to  whom,  as  the  patient  told  us  more  than  once  afterward,  the  idea 
of  breaking  her  promise  produced  extreme  moral  suffering. 

It  is  only  by  considering  the  social  environment  and  the  education 
that  the  patient  has  received,  that  the  physician  can  plan  his  methods  of 
psychotherapy.  This  man  with  severe  asthenia,  who  says  that  he  is 
incapable  of  any  intellectual  work,  will  have  read,  when  he  comes  to 
consult  his  physician,  nearly  all  the  neurological  literature  which  might 
interest  him.  However  fatigued  he  may  be,  being  accustomed  to  dis- 
cussion and  criticism,  he  will  already  have  laid  down  in  his  mind  a 
parallel  between  whatever  one  might  have  said  to  him  and  what  he  has 
read.  He  will  have  some  answer  ready  to  give  a  physician  on  every 
subject,  and  if  the  latter  is  taken  unawares  and  does  not  know  how  to 
give  him  a  ready  answer  in  return,  his  influence  will  become  decidedly 
weak.    Nevertheless,  when  one  meets  patients  who  are  reaUy  very  well 


380      THE  TREATMENT  OF  PSYCHONEUROSES. 

educated,  and  who  are  intelligent,  they  will  lend  themselves  readily  to 
your  reason.  The  situation,  however,  is  quite  otherwise  when  one  has  to 
deal  with  people  who  are  only  semi-educated,  and  who  are  conceited  by 
what  they  know,  which,  though  sometimes  covering  a  great  many  sub- 
jects, is  rarely  profound.  Proud  of  their  knowledge,  but  often  with 
very  limited  comprehension,  their  minds  are  like  a  glassy  surface,  which 
the  psychotherapeutist  finds  it  almost  impossible  to  gain  a  hold  on. 
Among  these  we  find  the  systematists  and  the  ultra-scientists  who  are 
as  firm  in  their  pathological  convictions  as  they  are  in  their  political 
ideas.  If  ''Monsieur  Homais"  had  been  neurasthenic,  he  would  no 
doubt  have  been  incurable. 

Such  patients  are  very  difficult  to  treat.  It  is  a  loss  of  time  to 
reason  with  them.  Proof  even  does  not  convince  them.  Moreover,  they 
are  often  so  sentimentally  atrophied  that  the  action  of  their  sthenic 
emotions  becomes  effective  only  when  it  has  to  do  with  their  pride,  or 
ambition,  or  their  own  good  opinion  of  themselves.  With  these  patients 
one  has  to  say,  apparently  quite  impressed  and  convinced  of  the  truth 
of  their  first  proposition,  *'Now,  you  are  an  intelligent  and  well-edu- 
cated man  .  .  .  and  you  will  understand  that  ..."  One  can  often  win 
them  by  flattering  when  it  would  be  impossible  to  make  any  appeal  to 
their  feelings. 

Such  cases  are,  fortunately,  rare,  for  such  subjects  possess  almost 
none  of  the  qualities  that  are  necessary  for  one  to  become  neurasthenic. 
One,  however,  meets  some  who  are  very  emotional  and  depressed,  be- 
cause they  consider  themselves  to  be  shamefully  misunderstood.  Being 
such,  which  is  quite  the  contrary  to  the  great  majority,  and  the  almost 
universal  condition  of  the  patient  which  we  have  to  deal  with,  they  are 
very  seldom  interesting  because  they  are  seldom  sympathetic.  To  tell 
the  truth,  it  is  not  their  fault  alone,  but  rather  and  above  all  the  fault 
of  the  environment  in  which  they  have  lived.  They  are  the  result  of 
erroneous  principles  of  education,  of  which  our  actual  state  of  society 
shows  perhaps  only  too  great  a  tendency  to  multiply  applications.  If 
in  such  patients  the  physician  does  not  find  a  single  responsive  chord, 
and  if  he  feels  himself  unable  to  penetrate  whatever  conviction  they 
may  hold,  one  last  resource  remains  for  them, — ^namely,  to  enforce  his 
authority  by  simply  giving  orders  and  commands.  One  will  often  be 
surprised  to  see  how  these  shallow,  undisciplined  characters  will  often 
accept  a  statement  or  consent  to  obey  when  they  merely  have  to  do  it 
passively.    If  one  lets  them  argue  or  reason,  one  is  lost. 

It  is  very  different,  on  the  other  hand,  with  patients  who  come 
from  the  class  of  people  living  nearer  to  a  state  of  nature,  who  have 
along  with  their  lesser  education  a  better  developed  sentimentality, 
great  spontaneity  of  feeling,  and  often  very  good  sense,  which  is  far 
from  being  a  detriment.     With  them  all  that  one  needs  to  do  is  to 


PSYCHOTHERAPY  SEEN  BY  DOCTORS  AND  PATIENTS.  381 

get  into  touch,  with  them,  to  talk  to  them  simply,  and  not  to  try  to 
dazzle  them  with  any  scientific  jargon  that  they  do  not  understand.  It 
is  not  necessary  for  the  physician  to  give  them  all  of  this  external  knowl- 
edge, at  least  as  far  as  anything  concerning  the  pathological  situation, 
which,  as  we  have  just  seen,  is  merely  a  therapeutic  threshold.  They 
have  hearts.  One  can  talk  to  them  about  their  feelings.  They  have 
good  sense,  and  a  straightforward,  almost  self-evident  argument  will 
always  strike  them  more  than  subtle  reasoning.  Along  this  line  suc- 
cess will  be  certain.  As  far  as  the  treatment  of , the  psychoneuroses  is 
concerned,  one  might  say,  more  than  under  any  other  circumstances, 
*  '  Blessed  are  the  simple-hearted,  for  they  will  be  cured.  '  ' 


CHAPTER  XXVII. 

PROPHYLAXIS  OP  THE  PSYCHONÈUROSES.      THE  MORAL  ROLE  OF  THE 
PHYSICIAN.      CONCLUSIONS. 

It  IS  a  very  commonplace  aphorism  to  say  that  prevention  is  better 
than  cure.  Prevention  simply  means  to  practise  hygiene,  and,  if  a 
hundred  years  from  now  an  historian  should  try  to  give  the  most 
characteristic  medical  work  of  our  present  century,  it  is  very  probable 
that  the  thing  that  would  strike  him  most  in  the  medical  evolution  of 
our  period  would  be  the  development  of  the  science  of  hygiene.  It  is  a 
subject  which  deals  with  the  masses.  It  lays  down  the  measures  to  be 
taken  to  avoid  epidemics  or  endemics.  It  is  also  interested  in  the 
individual,  looks  for  hereditary  defects,  and  outlines  the  best  method 
of  living  and  the  best  form  of  nourishment  that  could  combat  their 
possible  tendencies.  But  the  same  historian,  who  will  describe  our 
century  as  a  century  of  hygiene,  will  not  fail  to  express  his  astonish- 
ment that  physicians  seem  to  be  so  firmly  convinced  that  their  pre- 
ventive action  should  be  limited  exclusively  to  physical  life.  Is  it  pos- 
sible, however,  to  dissociate  in  any  being  a  physical  organism  on  the 
one  hand  which  will  function  autonomously  and  in  some  degree  spon- 
taaeously,  and  on  the  other  hand  a  psychic  organism  which  will  think 
and  feel  in  space  ?  It  is  true  that  physicians  are  willing  to  concede  that 
the  physical  may  exert  some  action  upon  the  moral  part  of  the  being. 
But  is  there  any  living  thing  or  relationship  in  life  which  is  so  one- 
sided? "We  do  not  think  so.  It  is  the  very  essence  of  life  to  be  com- 
posed of  phenomena  which  are  at  the  same  time  both  cause  and  effect. 
It  is  hardly  necessary  to  soar  into  metaphysical  abstractions  to  show 
that  it  is  by  that  very  thing  that  life  goes  on.  We  can  hardly  mention 
the  action  of  the  physical  and  the  moral  without  in  the  same  breath 
stating  the  reciprocal  action  of  the  moral  upon  the  physical,  and  if,  in 
the  course  of  the  preceding  pages,  we  have  made  our  thought  clear,  the 
reader  must  have  seen  that,  according  to  our  way  of  thinking,  all  the 
functional  manifestations  of  the  psychoneuroses  are  the  direct  result  of 
pathological  deviations  of  this  action  of  the  mental  upon  the  physical. 
Why  then,  as  we  have  a  physical  hygiene,  should  we  not  have  a  mental 
hygiene,  whose  care  it  is  to  prevent  diseases  of  the  psychism  just  as 
physical  hygiene  tries  to  prevent  diseases  of  the  body?  Why,  if  the 
physician  is  interested  in  treating  diseases  of  the  morals  and  the  devia- 
tions which  occur  between  the  psychophysical  relations,  should  he  leave 
the  work  of  correcting  and  avoiding  defects,  whose  causes  he  cannot 
exactly  determine  or  whose  consequences  foresee,  to  the  exclusive  care 
of  spiritual  directors  and  pedagogues?  That  certain  great  educators, 
382 


PROPHYLAXIS  OF  THE  PSYCHONEUROSES.     383 

whether  inspired  or  not  by  religious  and  philosophical  principles,  have 
been  able  to  lay  down  precepts  which  will,  empirically  at  least,  help  one 
to  realize  moral  hygiene  and  health,  is  a  fact  which  we  should  be  the 
last  to  discredit  or  to  fail  to  acknowledge.  This  does  not  prevent  us, 
however,  from  seeing  that,  if  we  want  to  find  definite  cause  of  this 
extraordinary  modern  increase  in  neuropathic  manifestations,  we  can- 
not attribute  it  to  anything  else  but  the  modem  lack  of  moral  education. 
The  rôle  that  others  have  not  filled  satisfactorily  or  have  left  unnoticed 
the  physician  has  the  right  to  adopt.  Knowing  the  importance  of 
hereditary  defects  and  being  able  to  determine  the  constitutional  element 
of  a  psychic  situation,  acquainted  through  long  experience  with  all  the 
woes  of  human  mentality,  knowing  how  these  are  constituted  and  what 
have  been  their  natural  consequences,  why  should  he  not  have  the  right, 
or  rather  would  it  not  be  his  duty,  to  go  on  still  further,  and  lay  down 
certain  generalizations  and  essentials  which  should  serve  as  moral  prin- 
ciples of  life?  Unquestionably  such  ideas  would  only  draw  forth 
raillery  from  some,  indifference  from  others,  and  scepticism  from  the 
majority.  Moral  hygiene  is  not  yet  taught  by  any  chair  in  the  faculty 
of  medicine,  and  the  physician  would  be  thought  to  have  lost  standing 
who  made  a  practice  of  palpating  a  patient's  sentiments  or  auscultating 
his  conscience.  There  are  orthopaedics  for  irregularities  in  the  spinal 
column  or  the  limbs,  but  there  are  not  (at  least  not  yet)  any  ortho- 
paedics for  irregularities  of  the  psychism  or  the  morale.  Would  people 
really  believe  that  a  physician  went  beyond  his  province  if  he  consented 
to  become  an  educator,  and  if,  knowing  why  and  how  a  moral  malady 
is  apt  to  start,  he  should  try  by  counsel  and  warning  to  strengthen  the 
patient's  resistance  against  it,  and  teach  him  how  to  avoid  those  factors 
which  predispose  him  to  it? 

This  function,  which  we  insist  is  right  for  the  physician,  would 
never  under  any  circumstances  be  denied  him  when  he  has  to  do  with 
patients  whom  he  has  cured.  Does  he  not  warn  a  neurasthenic  who  has 
regained  his  health  to  avoid  any  strong  emotions,  and  to  lead  a  very 
regular  life,  so  that  by  suppressing  causes  he  may  ward  off  effects? 
Emotion,  we  have  seen,  is  the  great  factor  of  the  psychoneuroses.  To  do 
everything  one  can  to  avoid  emotional  upsets  would  be  the  surest  guar- 
antee against  relapse.  But  the  very  essence  of  emotions  is  just  the  fact 
that  they  overwhelm  one  when  one  is  not  expecting  them,  and  the  patient 
who  has  given  way  so  to  sentimentality,  and  shown  so  much  personality, 
and  has  been  so  emotional  as  to  become  a  neurasthenic,  would  not  know 
how,  without  much  discomfort  and  emotional  conflict,  to  lessen  the  de- 
mands upon  his  life.  Therefore,  does  it  not  seem  that,  from  this  point 
of  view,  one  ought  to  practise  prophylaxis? 

It  is  of  no  use  to  try  to  escape  from  one 's  emotions  ;  the  chief  thing  • 
is  to  learn  to  judge  them.    But,  in  order  that  such  judgment  may  be 
possible,  it  is  necessary  that  the  whole  personality  of  the  patient  should 


384      THE  TREATMENT  OF  PSYCHONEUROSES. 

have  been  oriented  in  a  monoideistic  sense,  and  turned  toward  some 
practical  philosophical  or  religious  end.  It  seems  almost  elementary  to 
refer  every  happening  whatsoever  to  its  general  effect  upon  life,  and 
to  the  halt  or  the  retardation  which  it  may  cause  in  one's  journey  to  a 
given  goal.  Nevertheless,  there  are  very  few  persons  who  judge  things 
according  to  their  absolute  value  in  relation  to  life  taken  as  a  whole. 
However,  if  one  should  act  in  this  way,  one  would  avoid  many  of  the 
great  climaxes  which  result  from  trifling  causes.  If  one  could  teach  a 
patient  in  this  way  to  judge  the  value  of  his  emotions,  and  not  to  be 
too  much  affected  by  things  which  are  going  on  in  the  fields  along  his 
way,  but  which  offer  no  barrier  nor  even  a  trifling  obstacle  to  his  path, 
one  will  have  rendered  him  the  greatest  possible  service. 

But  it  is  not  only  facts  in  outside  life  which  are  apt  to  hinder  the 
general  onward  march  of  our  subject's  life;  he  is  held  back  by  the 
depths  of  his  own  nature,  by  his  previous  education,  by  all  the  bad 
habits  which  he  has  formed  during  the  course  of  his  disease,  which 
cause  him  frequently  to  halt  or  go  more  slowly.  Physical  and  moral 
auto-examination,  with  the  inhibition  of  the  will  which  necessarily  be- 
longs to  such  a  habit,  seems  to  us  to  play  a  very  important  rôle  from 
this  point  of  view.  It  must  be  understood  that  this  auto-examination 
may  be  the  natural  result  of  the  absolute  lack  of  confidence  in  himself 
which  the  patient  has  contracted  during  the  course  of  his  disease. 
But,  even  when  his  self-confidence  has  been  more  or  less  restored  to 
the  patient,  the  habits  which  he  acquired  previously  are  very  apt  to 
remain  with  him.  It  is  the  physician's  duty  to  show  him  his  danger, 
and  to  point  out  to  him  the  way  to  avoid  it  or  to  protect  himself  from 
it.  Here  his  advice  will  vary  according  to  different  personalities  as 
well  as  to  circumstances.  There  are  some  subjects  who  should  be  advised 
to  change  wholly  the  direction  to  which  they  have  been  accustomed.  Such 
would  only  be  the  case  with  those  who  are  constitutionally  scrupulous. 
Others  should  be  asked  to  give  up  absolutely,  without  any  question,  the 
habit  of  examining  themselves  physically,  and  to  refuse  to  attach 
any  importance  whatsoever  to  any  symptom  that  was  not  very  severe 
or  that  had  a  logical  cause.  And,  although  one  would  hardly  have 
the  right  to  tell  any  person  not  to  examine  his  conscience  or 
to  weigh  all  his  resolutions,  yet  he  might  at  least  be  asked  to 
proportion  the  time  spent  upon  his  self-examinations  to  the  impor- 
tance of  their  object. 

If,  as  we  think  we  have  shown,  a  patient  becomes  neurasthenic  because 
emotion  gains  the  upper  hand,  he  will  remain  normal  for  all  time  after 
he  is  once  cured,  if  he  can  only  learn  to  use  his  reason,  and  to  have  it 
always  on  hand  and  in  working  order  for  every  happening  in  life,  and  if 
he  knows  how  to  take  advantage  of  it,  to  correct  bad  habits  which  have 
already  been  formed. 


PROPHYLAXIS  OP  THE  PSYCHONEUROSES.     385 

We  have  had  a  great  many  subjects  to  treat  who  were  extremely 
neurasthenic.  We  have  been  able  to  follow  several  of  them  during  a 
good  part  of  their  lives.  There  are  some  who  have  sustained  great 
shocks,  and  others  who  have  gone  through  many  lesser  emotional  phases, 
but  they  have  always  known  how  to  withstand  them.  The  essential  thing 
in  well-ordered  psychotherapy  is  to  give  the  patient  a  greater  moral 
and  psychic  resistance  than  he  had  before  the  attack  of  weakness  which 
made  him  come  to  you. 

Is  it  possible  to  practise  a  prophylactic  therapy  for  hysteria  and  its 
symptoms  ?  This  seems  to  develop  naturally  from  the  explanations  given 
concerning  the  nature  of  these  symptoms.  The  patient  must  be  taught 
how  to  establish  a  more  resistant  intellectual  control,  as  well  as  to 
distrust  his  impressions  and  sensations,  chiefly  those  which  have  to  do 
with  his  own  special  emotional  reaction.  But  in  such  cases  the  most 
important  thing  seems  to  us  to  be  the  re-orientation  of  his  personality. 
Any  person  who  is  striving  toward  a  given  end,  whose  thoughts  and 
actions  are  coordinated  by  it,  loses  at  once  that  mentality  which  is  so 
peculiar  to  hysterics,  and  which  is  due,  as  we  have  seen,  to  all  kinds  of 
incoordinations.  When  we  really  wish  to  go  anywhere,  are  we  apt  to 
be  overcome  by  any  great  emotion  on  the  way,  or  to  be  stopped  by  an 
attack  of  hysterical  hemiplegia  ? 

There  are  still  subjects  other  than  confirmed  invalids  for  whom  the 
prophylactic  care  of  the  physician  can  be  of  peculiar  value.  We  refer 
to  children  whose  constitutional  emotionalism  is  seen  from  their  earliest 
years,  and  who  are  in  a  position  to  become  candidates  for  eventual 
neuropathic  disturbances,  but  which  could  be  prevented  by  well- 
managed  psychic  and  moral  hygiene.  Little  things  who  flush  or  turn 
pale  and  who  start  or  tremble  at  nothing,  who  are  alternately  sad  or 
exuberant,  who  fear  new  faces,  but  who  cling  desperately  to  those  in 
whom  they  have  confidence, — these  show  in  such  manner  their  physical 
emotionalism,  as  well  as  their  moral  emotionalism.  That  this  emotion- 
alism is  taken  advantage  of  in  bringing  them  up  is  too  often  the  case, 
and  mothers  who  are  somewhat  sentimental  develop  this  sentimentality 
still  more  in  their  children,  and  we  find  them  becoming  timid,  over- 
scrupulous, and  restless.  They  will  have  an  absolute  lack  of  confidence 
in  themselves,  considerable  self-esteem,  and  very  great  susceptibility. 
They  will  have  their  affections  excessively  developed,  understanding 
nothing  of  the  need  of  sharing  with  others.  They  will  not  dare  to  do 
anything,  but  will  suffer  from  everything;  although  they  will  need  to 
find  some  rational  direction  outside  of  themselves,  yet  they  will  not 
submit  to  any  but  sentimental  guidance.  They  will  be  in  a  perpetual 
state  of  agitated  excitement,  but  it  will  be  purely  internal  and  have  no 
application  to  anything.  The  most  sensible  person  who  tries  to  educate 
25 


386      THE  TREATMENT  OF  PSYCHONEUROSES. 

them,  unless  he  appeals  to  them  through  their  pride  and  sentiment,  will 
only  make  them  exasperated  and  rebellious. 

And  when  they  go  out  into  the  world  and  are  obliged  to  shift  for 
themselves,  by  reason  of  their  over-emotionalism  and  their  poor  equip- 
ment for  the  struggle,  they  will  run  all  the  more  risk  of  failing,  because 
their  very  inferiority  multiplies  the  opportunity  for  emotional  disturb- 
ances. They  will  only  take  a  half-hearted  interest  in  their  career,  which 
they  have  chosen  without  knowing  why.  They  will  fear  reproach  and 
will  not  stand  any  criticism.  Let  anything  happen  to  upset  them  in 
their  sentimental  life,  and  they  will  immediately  sink  into  a  state  of 
depression  and  will  become  neurasthenics. 

But,  if  their  education  had  been  better  directed,  if  they  had  been 
taught  to  feel  less  and  to  be  more  discriminating  in  their  judgment, 
such  unfortunate  consequences  could  have  been  avoided.  All  that  would 
have  been  necessary  would  be  to  teach  them  whenever  they  felt  a  wave 
of  emotion  to  look  for  the  cause  of  it,  and  to  get  hold  of  themselves  by 
examining  it,  as  it  were,  from  an  intellectual  point  of  view.  Later  on, 
it  would  have  been  enough  to  teach  them  that  all  feeling  or  sentiment 
is  dangerous  when  it  impedes  action,  and  that,  on  the  other  hand,  one 
cannot  demand  absolute  reciprocity  in  all  affairs  of  sentiment.  When 
they  were  quite  young  they  ought  to  have  been  accustomed  to  making 
prompt  decisions,  and,  if  one  had  been  able  by  the  wise  comprehension 
of  their  personality  to  start  them  off  along  certain  given  lines,  one  could 
undoubtedly  have  avoided  what  otherwise  had  been  the  almost  fatal 
failure  of  their  existence. 

Among  men  of  science  there  are  few  who,  like  the  physician,  are 
made  by  the  very  nature  of  their  studies  so  opposed  to  all  metaphysical 
abstraction.  The  mathematician  reasons  concerning  time  and  space,  the 
physicist  and  the  chemist  are  obliged  to  come  to  abstract  opinions  which 
are  beyond  physical  or  chemical  reasoning  concerning  the  formation  of 
matter,  the  physician,  who  deals  only  with  concrete  material  in  its  most 
complex  and  highest  forms,  has  no  tendency  to  indulge  in  abstract 
conceptions  which  take  him  away  from  practical  realities.  A  great 
mathematician  or  physicist  must  of  necessity  be  at  the  same  time  a 
philosopher  and  a  metaphysician.  Medicine  and  metaphysics,  however, 
are  two  terms  so  diametrically  opposed  to  each  other  that  they  can 
hardly  ever  be  brought  together.  The  physician  who  is  a  positivist, 
sceptical,  indifferent,  and  still  further  very  apt  to  be  ignorant,  abso- 
lutely refuses  to  let  his  mind  wander  off  into  the  realm  of  abstractions. 

But,  although  one  can  see  how  the  physician  who  is  interested  only 
in  the  body  may  show  the  greatest  indifference  to  all  the  problems  of 
life,  in  the  metaphysical  sense  of  the  word,  the  same  thing  is  by  no 
means  true  for  him  who  desires  to  be  a  physician  of  the  mind.  This  is 
the  case  of  the  psychotherapeutist. 


PROPHYLAXIS  OF  THE  PSYCHONEUROSES.     387 

We  are  certainly  most  strongly  opposed  to  any  systematic  psycho- 
therapy which,  starting  from  any  particular  philosophical  or  ethical 
system,  will  impose  a  point  of  view  which  is  often  quite  opposite  to  all 
their  previous  conceptions  upon  patients  who  are  still  lacking  in  control 
and  incapable  of  discussion.  We  hold  that  psychotherapy  must  appeal 
first  of  all  to  the  feelings  and  to  sentiment.  We  do  not  mean  by  that 
that  it  should  be  practised  upon  the  automatic  psychic  functions;  quite 
the  contrary,  it  should,  from  the  very  start,  be  addressed  to  the  per- 
sonality of  the  patient  on  those  points  which  are  the  most  secret  as  well 
as  the  most  quivering  and  responsive.  It  is  not  until  much  later,  how- 
ever, that  the  psychotherapeutist  may  dare  to  dwell  upon  abstract 
ideas,  without  running  the  risk  of  doing  the  patient  more  harm  than 
good,  by  introducing,  into  a  mentality  which  is  already  diffuse,  additional 
elements  of  uncertainty  and  disorientation.  We  have  already  said, — 
and  we  do  not  hesitate  to  repeat  it, — the  first  work  of  the  psycho- 
therapeutist  is  to  let  daylight  into  the  mentality,  the  morality,  and  the 
personality  of  his  patient,  and  to  bring  to  bear  upon  him  whatever 
arguments  may  help  to  build  up  his  former  personality  according  to 
whatever  intrinsic  value  his  personality  may  have  had. 

But  psychotherapy  should  never  be  advocated  without  knowing  that 
the  patient,  once  he  is  cured,  will  ask  his  physician  for  moral  support  and 
general  directions  concerning  his  life.  He  will  consult  him  as  if  he 
expected  him  to  lay  down  some  rule  which  will  henceforward  definitely 
protect  him  from  any  new  moral  failures  in  the  future;  he  will  also 
try  to  find  out  just  why  it  is  that  he  fell  ill,  and  how  he  was  cured.  He 
will  have  been  shown  that  what  he  must  try,  before  anything  else,  to 
do  is  to  regain  his  self-control,  and  to  establish  moral  control  over  his 
physique.  However  slight  may  be  his  intelligence  and  instruction,  he 
is  going  to  call  upon  you  to  settle  this  double  problem  of  free  will  and 
responsibility  on  the  one  hand,  and  relations  between  the  physique  and 
the  morale  on  the  other. 

According  to  our  ideas  it  would  be  very  ill  advised  for  a  psycho- 
therapeutist  to  refuse  to  enter  into  a  discussion  upon  these  points,  and 
to  draw  back  into  a  narrow  positivism  by  denying  the  principles  which, 
whether  metaphysical  or  not,  justify  and  warrant  his  methods  of 
procedure. 

There  is  one  case,  however,  where  the  physician  must  be  silent.  If 
he  has  to  deal  with  a  patient  who  has  very  strong  religious  convictions, 
what  need  has  he  for  metaphysics?  Faith  is  enough,  and  serves  the 
purpose  much  better  than  any  amount  of  reasoning.  Whether  the 
physician  be  sceptic  or  atheist,  he  has  no  right  to  attack  beliefs  which, 
as  experience  has  shown,  form  the  firmest  prop  and  the  surest  sup- 
port. Do  you  think  you  can  replace  by  any  deterministic  doctrine  or 
monistic  conception  what  constitutes  the  very  framework  of  their  per- 


388      THE  TREATMENT  OF  PSYCHONEUROSES. 

sonality  in  patients  who,  from  their  infancy,  have  been  accustomed  to 
believe,  possibly  without  reason,  but  nevertheless  with  faith  and  feeling, 
and  accustomed  to  find  in  their  faith  a  motive  in  life,  and  a  directing 
purpose?  By  no  means.  Such  a  procedure  would  seem  to  us  most 
dangerous,  and  almost  immoral.  It  would  be  much  better  for  the  patient 
to  think — and  there  is  nothing  to  be  ridiculed  in  this — that  you  are  a 
believer  like  himself,  rather  than  to  deprive  him  of  this  moral  founda- 
tion, formed  by  the  idealistic  conviction  that  lies  so  deep  in  his  heart. 

Does  this  mean  to  say  that  we  think  that  elsewhere  determinism  and 
monism  are  good  theories  to  uphold  in  patients  for  whom  psychotherapy 
by  persuasion  has  accomplished  its  work?  It  must  be  understood  that 
we  do  not  intend  to  discuss  the  intrinsic  value  of  these  philosophic  doc- 
trines. But  how  can  one  help  seeing  that  these  metaphysical  systems 
carry  with  them  the  denial  of  any  possibility  of  psychotherapy  by 
persuasion  ? 

If  we  have  been  able  to  make  ourselves  clear  in  the  pages  which 
have  preceded,  one  must  have  grasped  the  fact  that  we  hold  that  the 
whole  work  of  psychotherapy  ought  to  be  to  give  back,  to  the  subject 
who  has  lost  it,  the  full  strength  of  his  intellectual  control,  and  to 
restore  to  him  the  possibility  of  following  a  given  line  and  full  con- 
sciousness of  his  responsibility,  as  well  as  to  disentangle  in  him  the 
phenomena  of  the  physical  life  from  those  of  the  moral  life.  Now,  it 
is  very  certain  that  any  such  work  would  be  theoretically  impossible  if 
one  admitted  a  narrow  determinism  of  things,  if  one  denied  the  ex- 
istence of  any  responsibility  whatever,  and  if  one  refused  to  man, 
either  wholly  or  in  part,  the  liberty  of  self -guidance. 

How,  on  the  other  hand,  can  any  individual  be  assured  of  the  ascend- 
ency of  the  moral  and  psychic  life  over  the  physical  if  he  does  not  first 
admit  that  there  is  a  relative  independence  between — ^to  employ  the 
usual  phrases — ^the  body  and  the  soul  ? 

How,  in  other  words,  can  one  be  a  psychotherapeutist  if  one  is  a 
determinist  or  a  monist?  Although,  pushing  the  conception  to  its 
limit,  one  may  see  how  a  therapeutist  by  pure  suggestion  may  introduce 
new  factors  into  a  patient's  mind,  how  can  one  grasp  the  possibility  of 
making  over  the  subject's  personality  by  persuasion?  Yet  this,  how- 
ever, is  just  what  we  ask  our  patients  to  do.  The  emotional  actions 
which  can  be  brought  into  play  are  to  us  only  the  means  of  a  reawaken- 
ing and  recall  of  the  conscience  or  the  will,  which  are  purely  personal, 
of  our  subjects.  We  give  them  the  desire  to  be  cured,  but  it  is  they 
themselves  who  work  the  cure.  This  is  the  very  thing  which  constitutes, 
we  think,  the  great  superiority  of  psychotherapeutic  methods  by  per- 
suasion. They  develop  in  people  the  feeling  of  personality  and  re- 
sponsibility, they  increase  their  intellectual  control,  they  accustom  them 
to  plan  their  lives  and  direct  their  energies  by  themselves,  the  reverse 
of  all  other  psychotherapeutics,  which,  whether  it  is  acknowledged  or 


PROPHYLAXIS  OF  THE  PSYCHONEUROSES.     389 

not,  are  suggestive  therapeutics,  acting  on  the  human  mind  as  on  a 
mechanism  whose  machinery  one  tries  to  adjust. 

The  psychotherapeutist  who  wants  to  be  logical  with  himself  must, 
therefore,  plainly  tell  his  patients  that  he  thoroughly  believes  in  the 
free  will  of  man.  He  ought  also  to  tell  him,  that,  although  the  automatic 
psychic  functions  are  closely  allied  to  the  purely  physical  life,  he  does 
not,  however,  admit  that  there  is  any  identity  between  the  soul  and  the 
body,  and  that  his  function,  as  a  psychotherapeutist,  is  that  of  awaken- 
ing and  exercising  the  power  of  recall  over  those  superior  psycho- 
logical functions  which  emotion  and  life  have  rendered  diffuse  and 
which  are,  so  to  speak,  thrown  off  their  centre. 

There  are  a  great  many  individuals  who  do  not  share  this  way  of 
thinking.  They  will  discuss,  in  a  logical  way,  which  is  so  close  as  to 
become  disconcerting,  the  very  existence  of  their  free  will;  they  find  in 
the  very  denial  of  their  responsibility  an  excuse  for  their  moral  failures. 
The  physician  who  is  short  of  arguments  and  who  is  not  able  to  prove 
the  unprovable,  and  also  is  unable  to  persuade  his  subject  to  accept 
what,  for  him  as  a  physician,  may  be  an  article  of  faith,  will  often  have 
to  employ  the  following  argument,  which  we  have  frequently  used: 

Without  the  ideas  of  time  and  space,  which  in  themselves  may  be 
contingent,  there  could  be  no  possible  knowledge.  The  philosopher 
who  is  most  convinced  of  the  relativity  of  knowledge  must  none  the 
less  make  use  of  these  elementary  ideas.  Now,  if  time  and  space  form 
the  framework  of  knowledge,  responsibility  and  free  will  are  the  frame- 
work of  action.  One  cannot  act  if  one  is  not  conscious  of  his  free  will 
and  his  responsibility.  Deterministic  interpretations  are  only  inter- 
pretations a  posteriori.  They  may  follow  actions,  but  they  cannot 
demand  them,  quite  as  ideas  concerning  the  relativism  of  knowledge  are 
secondary  to  the  knowledge  itself,  which  in  the  absence  of  its  frame- 
work would  be  impossible.  At  all  events,  and  in  all  cases,  we  there- 
fore have  to  act  as  if  we  were  responsible,  and  as  if  we  were  enjoying 
our  absolute  free  will.  In  the  same  way  we  get  a  knowledge  of  things 
just  as  if  time  and  space  were  true  realities  outside  of  ourselves. 

This  manner  of  reasoning,  which  is  in  some  way  positivistic,  is  hardly 
more  than  an  argument  of  despair.  We  have  used  just  such  when 
subjects  were  trying  by  their  deterministic  ideas  to  find  an  excuse  for 
their  fall,  and  eventually  for  their  relapse. 

How,  otherwise,  could  a  subject  be  asked  to  control  the  phenomena 
of  his  physical  life,  so  far  as  his  psychism  has  a  physical  basis,  if  it 
might  so  be  called,  if  he  does  not  get  to  the  point  where  he  can  conceive 
that,  beyond  the  phenomena  of  psychologic  automatism,  there  is  a  place 
for  the  superior  moral  faculties,  which  are  used,  to  speak  truly,  by  the 
psychological  automatism,  but  which  are  not  wholly  constituted  or 
formed  by  it  ?  How  can  he  be  asked  to  combat  or  to  neglect  an  obsessive 
preoccupation,  if  he  imagines  that  this  preoccupation  is  furnished  by 


390     THE  TREATMENT  OF  PSYCHONEUROSES. 

a  mechanism  which  nothing  in  his  individualism  can  touch?  How  can 
he  be  asked  to  recover  his  judgment  by  his  own  strength  if  this  judg- 
ment is  practically  nothing  but  a  question  of  the  number  and  quality 
of  purely  passive  association  of  ideas?  The  clear  explanation  of  the 
automatic  and  involuntary  origin  of  so  many  preoccupations  and  slight 
obsessions  can  only  serve  as  a  starting-point  of  psychic  therapeutics 
in  so  far  as  one  admits  in  addition  the  independence  of  the  superior 
psychic  faculties. 

But  is  it  possible  to  prove  that  there  is  this  independence  between 
what  is  body,  and  consequently  susceptible  to  all  physical  and  chemical 
actions  of  the  organism,  and  the  mind,  properly  so  called,  in  the  sense 
in  which  the  ancient  idealistic  philosophers  used  the  word? 

The  practical  demonstration  of  this  independence  is  a  direct  result 
of  this  fact,  that  patients  have  been  able,  by  the  action  of  their  will 
and  their  intelligence  alone,  to  regain  that  full  consciousness  and 
mastery  of  themselves  which  prevented  the  repeated  incursions  of  the 
automatism  into  the  realm  of  consciousness  which  was  more  or  less 
disturbed  by  emotional  action.  And  the  argument  may  be  summed  up 
in  the  following  way  by  telling  the  patients:  "You  see  that  you  have 
been  able  to  gain  the  mastery  over  yourself  since  you  have  known  how  to 
cure  yourself."  We  have  hastened  to  bring  to  a  close  this  paragraph, 
which  has  led  us  to  what  we  must  frankly  confess  are  the  cloudy  heights 
of  pure  abstraction.  It  has,  however,  seemed  to  us  that  these  things 
should  be  said,  because  we  have  an  idea,  and  a  very  definite  one,  that 
deterministic  or  monistic  doctrines  have  done  a  great  deal  of  harm  to  a 
great  many  patients. 

On  the  other  hand,  much  good  can  be  done  to  numerous  patients  by 
showing  them  that  the  surest  guarantee  against  all  little  and  even 
great  emotions  is  to  build  up  either  an  ethical  or  a  philosophical  or 
a  religious  ideal.  This  idea  is  one  on  which  we  have  often  insisted,  be- 
cause it  has  seemed  to  us  to  have  the  value  of  experience.  Life  shows 
every  day  that  those  have  been  the  best  able  to  stand  up  under  anxiety, 
grief,  or  various  vicissitudes  who  have  known  how  to  create  objectively 
an  ideal  outside  of  themselves,  no  matter  what  it  may  be,  but  whose 
progressive  realization  has  brought  unity  into  their  life.  Those  men, 
on  the  other  hand,  whose  life  seems  to  be  lived  day  by  day,  as  it  were, 
without  any  purpose  or  direction,  who  seem  always  to  be  stopping  and 
losing  themselves  or  wandering  into  all  sorts  of  lanes  and  blind  alleys, 
are  much  more  poorly  equipped.  Without  any  definite  convictions,  they 
have  no  definite  reasons  to  go  in  one  direction  more  than  another,  and 
the  slightest  obstacle  which  they  meet  in  their  path  leaves  them  standing 
still  upon  their  way. 

If  it  is  true,  as  we  think  it  to  be,  that  moral  health  results  from  the 
free  development  of  the  personality,  how  can  we  help  but  see  how  great 


PROPHYLAXIS  OF  THE  PSYCHONEUROSES.     391 

an  interest  there  is  in  directing  this  into  a  path  which,  by  its  very- 
nature,  offers  the  greatest  security  and  an  almost  perfect  guarantee 
against  the  accidents  of  existence? 

Having  now  reached  the  end  of  our  study,  we  feel  that  it  would 
be  wise  to  sum  up  in  a  few  liiies  those  ideas  which  seem  to  us  to  have 
the  most  characteristic  importance. 

So   we   shall  say: 

1.  All  the  functions  may  be  disturbed  by  the  improper  interference 
of  the  mind.  It  is  in  this  way  that  functional  manifestations  are 
created. 

2.  This  interference  of  the  mind  has  in  almost  every  case  some 
emotional  cause  for  its  origin. 

3.  Emotion  may  act  by  repeated  actions.  It  then  creates  neuras- 
thenia— the  syndrome  of  emotional  preoccupation. 

4.  Emotion  may  act  by  the  sudden  action  of  dissociation.  Under 
these  conditions  it  results  in  hysterical  symptoms. 

5.  The  action  of  emotion  which  creates  the  psychoneuroses  and  their 
sjrmptoms  can  only  take  place  on  emotional  soil.  But  when  the  eventual 
neurasthenic  is  essentially  obsessable  and  the  hysteric  is  by  definition 
an  unstable  and  incoordinated  personality: 

6.  We  hold  that  it  is  wrong  to  have  included  under  neurasthenia, 
which  is  an  affection  of  psychic  origin,  the  various  asthenias  of  organic 
origin  which  have  nothing  in  common  with  them  but  symptoms  of 
fatigue. 

7.  Although,  as  far  as  their  secondary  phenomena  are  concerned, 
the  psychoneuroses  may  be  treated  in  various  ways,  there  is  but  one 
etiological  therapy  for  them, — ^namely,  that  of  psychotherapy. 

8.  There  is  but  one  legitimate  form  of  psychotherapy, — ^namely,  the 
psychotherapy  of  persuasion,  which  should  be  addressed  both  to  the 
symptoms  and  to  the  mental  and  moral  make-up  which  has  permitted 
them  to  become  established. 


INDEX 


Amaurosis,  160 
Amenorrhœa,  81 
Anaesthesia,  143 

and  suggestion,  146 
Analytical  study,  1 
Anguish  and  emotion,  224 
Anorexia,  elective,  10 

mental,  2 

primary  mental,  4 

secondary,  5 

social,  5 

Anuria,  49 

Appetite,  disturbances  of,  2 

excess  of,  8 
Appendicitis,  false,  42 
Arrhythmia  of  heart,  93 
Arrived  neurasthenics,  190 
Association  of  ideas,  307 
Astasia-abasia,  127,  129 
Asthenia,  116 

therapy  for,  356 
Asthma,  pseudo-,  86 
Attention  diflSculties,  186,  195 
Auditory  phenomena,  161 
Autointoxication  hobbies,  215,  216 
Automatic  work,  112 

Babinski  and  hysteria,  104 
Bladder,  physiology  of,  51 
Bradycardia,  93 
Bromidrosis,  103 

Cardiac  phobias,  93 
Cardiovascular  reeducation,  350 
Character  changes,  192 
Chest,  oppression  of,  88 

pains,  90 
Chorea,  hysterical,  129 
Choreiform  movements,  131 
Chromidrosis,  103 
Coitus,  incomplete,  71 
"Cold,  catching,"  108 
Constipation,  nervous,  39 

treatment  of,  331 
Contractures,  136 
Coryza,  164 
Cyclothymia,  246 


Defsecation  troubles,  37 

Defence  contractures,  140 

Defloration,  70 

Diagnosis  functional  manifestations,  205 

Diarrhoea,  nervous,  38 

treatment  of,  330 
Diet,  328 
Dietary  fads,  20 
Digestive  symptoms,  2 

distm-bances,  11 
Dilatation  of  stomach,  32 
Disgust  for  food,  36 
Disharmony  and  asthenia,  120 
Dissociation  by  emotion,  264 
Distractions,  187 
Dubois  school,  iv 
Dyspepsia  of  neurasthenics,  16 

Ejaculation,  premature,  64 
Emotion  and  hysteria,  104 

persistence  of,  239 

in  psychoneuroses,  219 

and  skin,  101 
Emotional  attacks,  224 
Emotions  from  internal  stimuli,  220 
Emptiness,  191 
Enterocolitis,  43 
Equilibrium  changes,  125 

therapy  of  disturbances,  358 
Examination  of  neuropath,  286 
Exhaustion,  109 

Fads  of  diet,  20 

False  gastropath  types,  207 

gastropaths,  10 

gynopathies,  79 

prostatics,  56 

pulmonaries,  89 

urinaires,  57 
Fatigue,  109 

and  will,  114 
Fear  of  insanity,  174 

of  pregnancy,  71 
Floating  kidney,  46 
Food  phobias,  10 
Freudian  school,  iv 
Frigidity,  71,  75,  76 
Functional  manifestations,  1 
conception  of,  271 

and  organic,  199 

393 


394 


INDEX 


Gastric  obsessions,  17 

phobia,  16,  17 

symptoms,  14 

therapy,  320,  324 
Gastropath,  treatment  of,  320 
Gastropaths,  false,  10,  22 
Genital  disorders  in  man,  58 

manifestations,  58 

pains,  75 

spasms,  72 
Gynaecological  signs,  therapy  of,  346 

Hœmatidrosis,  103 
Hœmoptysis,  hysterical,  91 
Headache,  180 

therapy,  365 
Heart,  emotional  action,  92 

fixations,  92 

phobias,  93 
Hemianaesthesia,  143 
Hiccough,  91 
Hunger,  false,  8 
Hydrorrhœa,  163 
Hygiene,  mental,  382 
Hyperacusis,  161 
Hyperaesthesia,  151 
Hypnotic  method,  279 
Hypnotism,  278 
Hypochondriasis,  246 
Hysteria,  diagnosis,  241 

special  therapy,  369 
Hysterical  anaesthesia,  144 

chorea,  129,  132 

contractures,  138 

haemoptysis,  91 

pains,  153 

paralyses,  138 

skin  disturbances,  103 

symptoms,  263 

Illogic,  209 
Imitation,  147 
Impotence,  63,  65 
Incontinence  of  urine,  53 
Individuality  and  emotions,  228 
Insanity,  fear  of,  194 
Insomnia,  168 

and  fatigue,  177 

mechanisms  in,  173 

therapy  for,  361 
Intellectual  capacity,  186 
Intestinal  neuropathies,  42 
Introduction,  xiii 
Ischuria,  49 
Isolation,  311 

types,  314 


Itching,  107 

Kidney,  floating,  46 
secretions,  47 

Laryngeal,  82 
Lethargy,  179 
Lumbago,  122 

Madness,  fear  of,  194 
Masturbation,  59,  71 
Mental  anorexia,  2 

fatigue,  186 

fragility,  265 

hunger,  false,  8 

rest,  314 

substratum,  292 
Micturition,  51 
Milk  diet,  328 
Moral  factors,  207 

health,  390 

rest,  317 
Mucomembranous  enterocolitis,  43 
Muscular  fixations,  109 
Mutism,  184 
Mysticism,  4 

Nasal,  82 

Nervous  constipation,  39 

diarrhoea,  38 

movements,  135 
Neurasthenia,  diagnosis,  241 

and  emotions,  233 

organic  conceptions,  214 
Neurasthenic  dyspepsia,  16 

how  to  become,  250 

fatigue,  110 

major,  treatment,  306 

mechanism,  256 
Neuropath,  examination  of,  286 
Neuropathic  vomiting,  34,  36 
Neuropathy  of  intestine,  42 
Noise,  irritability  to,  162 

Obsession,  189 
Obsessions,  gastric,  17 
Ocular  phenomena,  159 
Onanism,  59 
Oppression  of  chest,  88 
Organic  conceptions  of  neurasthenia,  214 
and  functional,  199 

Pains  in  chest,  90 

genital,  75 

hysterical,  153 

therapy  for,  359 
Palpitation  of  heart,  93 
Paraesthesiae,  156 
Paralyses,  136 


INDEX 


395 


Pericardial  phobias,  93 
Persuasion,  283 
Phobia  of  food,  10 

gastric,  16,  17 
Phobias  of  heart,  93 

of  skin,  106 
Phobic  changes,  194 
Photophobia,  158 
Physical  and  psychical,  227 

rest,  315 

Pollutions,  61 
Polydipsia,  49 
Polyuria,  49 
Preface,  vii 
Pregnancy,  false,  80 

fear  of,  71 
Premature  ejaculation,  64 
Prophylaxis  of  psychoneuroses,  382 
Prostatics  false,  56 
Pseudo-asthma,  86 

gastropathies,  16,  22 

gynaecological,  58 
Psychasthenia,  248 

of  Janet,  121 
Psychic  therapy,  366 
Psychical  and  physical,  227 
Psychoneuroses,   critical  study  of  treat- 
ment, 274 

emotional  origin,  238 

prophylaxis,  382 
Psychotherapy,  274 

adjuvants,  311 

general,  305 

and  patient,  373 

and  physician,  373 

and  religion,  377 
Pulmonaries,  false,  89 
Punishment  in  hysteria,  371 
Pupillary  changes  in  hysteria,  158 

Reflex  disturbances,  181 
Religion  and  psychotherapy,  377  ' 
Respiration,  interchange,  84 
Respiratory  fixations,  82 

phobias,  89 

signs,  therapy  of,  347 
Retention  of  urine,  53 

Secretory  changes,  102 
Sensibility  disturbances,  141 
Sexual  excess,  60 

manifestations  in  women,  69 
neurasthenia,  61 

in  women,  78 
therapy,  336 

in  women,  342 


Simulation,  146 
Skin  changes,  101 

and  emotion,  101 

and  hysteria,  103 

manifestations,  therapy  of,  351 

phobias,  106 
Sleep  disturbances,  168 

therapy  for,  361 

Smell,  changes  in,  163 
Speech  disturbances,  184 
Spermatorrhoea,  63 
Stasobasophobia,  127 
Sterihty,  71 

Stomach,  dilatation  of,  16,  32 
Suggestion  in  cardiac  phobias,  95 

and  imitation,  147 

indirect,  182 

waking,  281 
Syncope,  92 
Synthesis,  213 

Tachycardia,  93 

Taste  changes,  165 

Technique  of  examination,  287 

Therapy  of  digestive  organs,  320 

Throbbing  of  vessels,  98 

Tics,  131 

Topalgia,  153 

Translator's  preface,  iii 

Tremors,  131 

Trophic  symptoms,  102,  103 

Urethral  pain,  55 
Urinaires,  false,  57 
Urinary  incontinence,  53,  54 

manifestations,  46 

pains,  55 

retention,  53 

secretions,  47 

therapy,  333 

Vaginismus,  73 
Vascular  mechanisms,  98 
Vasoconstriction,  101 
Vasomotor  changes,  98 
Vertigo,  auricular,  162 
Violation,  71 

Vision,  disturbances  of,  157 
Vocal  cord,  spasm  of,  83 
Vomiting,  16,  34 

emotional,  36 

treatment  of,  329 

Work,  automatic,  112 
Worry  and  grief,  207 


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